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Fractures of the Maxillae and Mandible*
FRACTURES OF THE MAXILLAE AND MANDIBLE* B y C. M . L o g s d o n , D .D .S., Hines,
U R IN G the past seven and oneh alf years,' nearly 200 admissions to the U . S. Veterans Hospital, Hines, 111., for fracture of the jaw , have been recorded. M ore than 95 per cent of this group were W orld W ar veterans whose average age, at the present time, is 46 years. Spanish Am erican W ar veter ans, whose average age, at the present time, is 66 years, constitute the re mainder. T h e age is mentioned because fractures do not heal so quickly in adults as in children. Treatments and proced ures are different in m any instances, and the cause of the fracture m ay vary some what between the two age groups. For purposes of this study, fractures of the jaw will be classified as follows: 1. Fractures showing an absence of infection and little displacement. 2. Fractures showing moderate displacement associ ated with infection. 3. Fractures showing complications with considerable displace ment and infection.
D
T O P O G R A P H IC REG IO N S IN V O LV E D
M ore than 95 per cent of the jaw frac tures mentioned are of the mandible, pos sibly because of its horseshoe shape and anatom ic location. T he region at the angle of the ramus ranks second to the area near the mental foramen in fracture location in this group. Occasionally, fracFrom the Dental Clinic, O ral Surgery Sec tion, U . S. Veterans Facility. •Published with the permission of the medi cal director of the Veterans Administration, who assumes no responsibility for the opinions expressed or the conclusion drawn b y the author.
Jour. A .D .A., Vol. 27, March 1940
111.
tures occur at the condyle neck of the mandible. W hen the jaw receives a blow sufficient to cause a fracture near the mental fora men, often a fracture occurs at the angle of the ramus on the opposite side. Such bilateral fractures frequently result from “slugging” or “ holdups.” Fractures of the maxillae occur anteroposteriorly, diagonally and laterally. Anteroposterior fractures of this bone usually occur near the median line. S Y M P T O M S AN D DIAG N O SE S
Symptoms suggesting fracture of the jaw include pain, impairment of both mastication and occlusion and displace ment of the fragments, followed by edema, swelling and infection of the in volved area. T h e temperature may rise to I02°F. or higher when there is extensive acute infections. Roentgenograms of the parts are valuable aids in fracture diag nosis, and, unless the entire bone is in cluded in the film, the reproduction m ay not present a true picture of the condi tion. Fractures that have not been sus pected have been found when the entire mandible was included in the roentgenographic examination. CA U SA T IV E F A C TO R S
M ore than 50 per cent of the patients treated at Hines Hospital for fractured jaws were slugged during holdups. In juries received from automobile accidents held second place. T w o patients had fractures of the mandible from aeroplane wrecks. T h e case history of one patient
389
390
T h e Journal o f the Am erican D en ta l Association
revealed that a mandibular fracture of the first type occurred during the process of normal mastication, in the area o f an impacted third molar. A roentgenogram taken of this area twenty-four hours later disclosed no noticeable pathologic condition. Rem oval o f teeth was not re corded at any time as the cause of frac ture. T R E A T M E N T AN D PRO CE D U R E
Reduction, fixation and postoperative care are essential factors in the treatment of jaw fractures. Interm axillary wiring has been a popular method o f treatment of these fractures since late in the last ccntury. This method has been much re vised within the last few years, and its indications and application are well known. For simplicity and effectiveness, in the presence of teeth, this principle of treatment is more com monly indicated than other methods and it is probably most widely used. T h e extensive use of elastic tension in the treatment of jaw fractures has been the greatest aid available thus far. We have utilized this procedure since 1927. T h e method can be satisfactorily used in dividually or in combination with inter m axillary wiring. O ne method of reducing and fixing a fractured mandible in the region of the mental foramen, with teeth present, as sociated with considerable displacement and infection, will be reviewed. A con stant pull by the muscles of mastication, except the external pterygoid, displaces the posterior fragment upward in such instances, but an opposite pull exists on the anterior fragment. T h e pull of the anterior belly of the digastric muscles, assisted by the other suprahyoid muscles, displaces this fragm ent downward. Therefore, the anterior teeth will be far from occlusion. B y manipulation, it would be rather difficult to reduce this anterior fragment to normal apposition. A W inter type arch bar, with lugs at tached, is ligated to the upper teeth.
Likewise, an arch bar is attached to the teeth of the lower arch. T h e teeth of the posterior fragment are not yet wired to the arch bar. Rubber bands, in sufficient quantity, are placed over the lugs of the lower arch bar and attached over the lugs of the upper arch bar, the anterior fragment being thereby gradually pulled into normal position. It m ay require from twenty-four to forty-eight hours for this procedure. T h en the teeth of the poste rior fragment are ligated to the lower arch bar. H ow to hold the fractured fragments in normal apposition is the next problem. This is usually done by fixing the teeth o f both arches in normal occlusion until healing of the fracture ensues. W ire liga tures, silk or cotton ligatures or rubber bands m ay be used. W ire ligatures are not so comfortable to the patient as the others. T h e silk or cotton ligatures will stretch and it will be necesary to change them every five days or oftener, which is the m ain disadvantage. T h e rubber bands have proved satisfactory in many instances for holding the arches in appo sition. Elastic tension may, in the absence of wiring, be used in reducing and treating fractures of the mandible. T h e type of fracture just mentioned can be so treated. M etal bands, with attachments for the rubber bands, are placed over the teeth which are to be used in reduction and fix ation. These rubber bands are attached over the hooks of the m etal caps or bands and over the hooks of the opposite arch. T h e fragments will then be pulled where desired. T h ey can be fixed b y holding the teeth of both arches in apposition by means of rubber bands until the fracture heals. T h e teeth used should be well seated in the bone and the tension should not be too strong, as single teeth m ay be pulled from their sockets overnight, if the pull is too strong. Loose teeth or those in the line of frac ture should never be utilized in fracture treatment. N o fixed rule is followed as
391
Logsdon— Fractures of M axillae and M andible
regards removal of teeth in the line of fracture or those badly loosened by the injury. Should a fracture occur in the region of the most posterior tooth of the mandible, generally this tooth should not be removed at first, as its presence pre vents the posterior fragment from being displaced upward. A tooth in such a posi tion should be retained for at least three weeks. Then , if necessary, it could be re moved, and doubtless the distal fragment would not be displaced. Should this frag ment be pulled upward, a small splint can be constructed to hold it in normal position. Splints of this type can be used where the arches are wired in apposition. T h e rem oval of all loose teeth in the line of fracture, unless they are badly needed to hold the fragment in position, is indi cated. T h eir retention often results in infection. Elastic tension can also be applied in the treatment of fractures of the maxillae. Following is a case in point: T h e left m axilla was fractured anteroposteriorly. T h e fractured fragm ent was displaced lingually and the teeth of this fragm ent were i cm. lingually from the lower teeth. A n arch bar was ligated to the teeth of the right maxilla. T h e bar extended around the arch to the m olar teeth on the opposite side, about i inch labially and buccally from the teeth of the fractured fragment. Tw enty-gage wires were twisted around three teeth of the frac tured fragm ent and the ends bent to form hooks. Elastic bands were placed over these hooks and the lugs of the arch bar. T h e displaced fragment was pulled into normal occlusion and then the teeth of the fractured region were ligated to the arch bar. T h e upper and lower teeth were then wired in apposition and were held there for four weeks, during which a union was formed. A similar case was reduced by the same procedure. Instead of immobilizing the arches together, the operator used a horseshoe shaped vulcanite splint fitted to the palate to hold the fractured frag
ment in position and allowing movement of the mandible. T h e rubber bands mentioned are made from rubber tubing about one-eighth inch in diameter. It must be flexible and o f a good quality. T h e wires used to ligate the arch bars to the teeth are 25-gage and should be easy to manipulate. Wires used in m aking hooks for pulling and holding purposes should be about 20rgage and rather rigid. T h e wires should be firmly ligated around the teeth and should not impinge on the soft tissues. O pen reduction and other surgical pro cedures are sometimes indicated in fra c ture treatment. Splints of various types and head and chin appliances are also used in treating fractures o f the jaw . Postoperative care should follow reduc tion and fixation of the fractured jaw. It is of paramount importance that ade quate drainage be established and m ain tained in the presence of infection. M ore often than not, extra-oral drainage is in dicated rather than intra-oral. Rubber drains in the form of tubes or strips should be inserted in the incision. T h ey should be changed every twenty-four to fortyeight hours. T h e oral cavity should be kept as clean as is possible during fixation. L un g abscesses and other com plications m ay result from oral sepsis while the arches are wired. Potassium permanganate, 1:3000, for mouth irri gation, is valuable as a cleanser and de odorant, especially in the presence of wires. U N IO N O F F R A C T U R E S
Bony union and normal function w ith out disfigurement are the results desired in the treatment of ja w fractures. Normal occlusion is the criterion in the reduction and fixation of these parts. O nly two ex amples of fibrous union were recorded in nearly 200 patients treated at Hines for fractured mandibles. T h e roentgeno grams taken one year after fixation revealed the absence of bone in the frac tured area. O ne jaw was again roentgen-
392
T h e Journal o f the Am erican D en ta l Association
ographed a year later, but there was no apparent change. Functionally and clinically, fibrous union was in both cases normal. Both patients had tuberculosis. In other patients w ith this disease, frac tures have healed normally. Four pa tients had neither fibrous nor bony union, but each fracture was several weeks old, and treatment had been instituted before the patient was received at Hines, and unusual complications were already pres ent. Fractured jaws should generally be re duced and fixed immediately. H owever, in the presence of severe infection and swelling of the parts, shock and other complications, temporary measures can be applied, in the form of application of head and chin straps, etc.; but reduction and fixation should be accomplished soon after complications have subsided. A type two fracture of the mandible in the area of the mental foram en of five months’ duration, without treatment, was included in the Hines group. By elastic tension, the displaced anterior fragment was pulled into normal posi tion, the procedure requiring about one week. T h e fragments were then fixed and were held there for four months. In the meantime, bony union o f the parts took place. SUM M ARY
N early 200 jaw fractures have been treated at the U. S. Veterans Hospital, Hines, 111., during the past seven and one-half years. About 95 per cent of pa tients in this group were W orld W ar vet erans whose average age at the present time is 46 years. Spanish Am erican W ar veterans, whose average age a t the pres
ent time is 66, constitute the remainder. M ore than 95 per cent of these fractures were of the mandible. T h e mental fora men was the most common area of frac ture, the area at the angle of the ramus ranking second. A m ajority of these fractures were caused by “ slugging.” Injuries from auto mobile accidents were listed as the second cause. Interm axillary wiring, in combi nation with elastic tension, was the method most used in the treatment of these fractures. T h e average time of fix ation was eight weeks, and a large m ajor ity o f these fractures were infected. U nion occurred in all but four instances. T h e fibrous union in two cases mentioned elsewhere is not included among the four cases of non-union. b ib l io g r a p h y
1. A d d i s o n , P. J.: Treatm ent of Non-Union and Loss of Substance in Fracture of Edentu, lous M andible. J.A .D .A ., 25:1081-1084, July
1938. 2. A l b e e , F. H . : Treatm ent of Non-Union with or W ithout Loss of Bone. M il. Surgeon, 78:413-427, June 1936. 3. A u f d e r h e i d e , P. J.: Treatment of Frac tures of M axilla, M andible and Other Bones of Face. J .A .D .A ., 21:950-961, June 1934. 4. B l a ir , V . P.: Surgery and Disease of M outh and Jaws. Ed. 3. St. Louis: C. V . Mosby Company, 1918, pp. 131-145. 5 . G i l k i s o n , C . C .: Treatment of M axillo mandibular Fractures. M il. Surgeon, 8 4 : 4 4 1 4 5 1 , M ay 19 3 9 .
6. G i n g r a s s , R . P.: Early Management of Facial Fractures. J.A .D .A ., 25:693-706, M ay
1938. 7 . G r i m s o n , K . S.: Healing of Fractures of M andible and Zygom a. J.A .D .A ., 24:14581469, September 1937.
8. K a z a n j i a n , V . H . : Treatment of Auto mobile Injuries of Face and Jaws. J.A.D .A.,
2 0 :757 - 772 , M a y 1933.
U R IN G the past seven and oneh alf years,' nearly 200 admissions to the U . S. Veterans Hospital, Hines, 111., for fracture of the jaw , have been recorded. M ore than 95 per cent of this group were W orld W ar veterans whose average age, at the present time, is 46 years. Spanish Am erican W ar veter ans, whose average age, at the present time, is 66 years, constitute the re mainder. T h e age is mentioned because fractures do not heal so quickly in adults as in children. Treatments and proced ures are different in m any instances, and the cause of the fracture m ay vary some what between the two age groups. For purposes of this study, fractures of the jaw will be classified as follows: 1. Fractures showing an absence of infection and little displacement. 2. Fractures showing moderate displacement associ ated with infection. 3. Fractures showing complications with considerable displace ment and infection.
D
T O P O G R A P H IC REG IO N S IN V O LV E D
M ore than 95 per cent of the jaw frac tures mentioned are of the mandible, pos sibly because of its horseshoe shape and anatom ic location. T he region at the angle of the ramus ranks second to the area near the mental foramen in fracture location in this group. Occasionally, fracFrom the Dental Clinic, O ral Surgery Sec tion, U . S. Veterans Facility. •Published with the permission of the medi cal director of the Veterans Administration, who assumes no responsibility for the opinions expressed or the conclusion drawn b y the author.
Jour. A .D .A., Vol. 27, March 1940
111.
tures occur at the condyle neck of the mandible. W hen the jaw receives a blow sufficient to cause a fracture near the mental fora men, often a fracture occurs at the angle of the ramus on the opposite side. Such bilateral fractures frequently result from “slugging” or “ holdups.” Fractures of the maxillae occur anteroposteriorly, diagonally and laterally. Anteroposterior fractures of this bone usually occur near the median line. S Y M P T O M S AN D DIAG N O SE S
Symptoms suggesting fracture of the jaw include pain, impairment of both mastication and occlusion and displace ment of the fragments, followed by edema, swelling and infection of the in volved area. T h e temperature may rise to I02°F. or higher when there is extensive acute infections. Roentgenograms of the parts are valuable aids in fracture diag nosis, and, unless the entire bone is in cluded in the film, the reproduction m ay not present a true picture of the condi tion. Fractures that have not been sus pected have been found when the entire mandible was included in the roentgenographic examination. CA U SA T IV E F A C TO R S
M ore than 50 per cent of the patients treated at Hines Hospital for fractured jaws were slugged during holdups. In juries received from automobile accidents held second place. T w o patients had fractures of the mandible from aeroplane wrecks. T h e case history of one patient
389
390
T h e Journal o f the Am erican D en ta l Association
revealed that a mandibular fracture of the first type occurred during the process of normal mastication, in the area o f an impacted third molar. A roentgenogram taken of this area twenty-four hours later disclosed no noticeable pathologic condition. Rem oval o f teeth was not re corded at any time as the cause of frac ture. T R E A T M E N T AN D PRO CE D U R E
Reduction, fixation and postoperative care are essential factors in the treatment of jaw fractures. Interm axillary wiring has been a popular method o f treatment of these fractures since late in the last ccntury. This method has been much re vised within the last few years, and its indications and application are well known. For simplicity and effectiveness, in the presence of teeth, this principle of treatment is more com monly indicated than other methods and it is probably most widely used. T h e extensive use of elastic tension in the treatment of jaw fractures has been the greatest aid available thus far. We have utilized this procedure since 1927. T h e method can be satisfactorily used in dividually or in combination with inter m axillary wiring. O ne method of reducing and fixing a fractured mandible in the region of the mental foramen, with teeth present, as sociated with considerable displacement and infection, will be reviewed. A con stant pull by the muscles of mastication, except the external pterygoid, displaces the posterior fragment upward in such instances, but an opposite pull exists on the anterior fragment. T h e pull of the anterior belly of the digastric muscles, assisted by the other suprahyoid muscles, displaces this fragm ent downward. Therefore, the anterior teeth will be far from occlusion. B y manipulation, it would be rather difficult to reduce this anterior fragment to normal apposition. A W inter type arch bar, with lugs at tached, is ligated to the upper teeth.
Likewise, an arch bar is attached to the teeth of the lower arch. T h e teeth of the posterior fragment are not yet wired to the arch bar. Rubber bands, in sufficient quantity, are placed over the lugs of the lower arch bar and attached over the lugs of the upper arch bar, the anterior fragment being thereby gradually pulled into normal position. It m ay require from twenty-four to forty-eight hours for this procedure. T h en the teeth of the poste rior fragment are ligated to the lower arch bar. H ow to hold the fractured fragments in normal apposition is the next problem. This is usually done by fixing the teeth o f both arches in normal occlusion until healing of the fracture ensues. W ire liga tures, silk or cotton ligatures or rubber bands m ay be used. W ire ligatures are not so comfortable to the patient as the others. T h e silk or cotton ligatures will stretch and it will be necesary to change them every five days or oftener, which is the m ain disadvantage. T h e rubber bands have proved satisfactory in many instances for holding the arches in appo sition. Elastic tension may, in the absence of wiring, be used in reducing and treating fractures of the mandible. T h e type of fracture just mentioned can be so treated. M etal bands, with attachments for the rubber bands, are placed over the teeth which are to be used in reduction and fix ation. These rubber bands are attached over the hooks of the m etal caps or bands and over the hooks of the opposite arch. T h e fragments will then be pulled where desired. T h ey can be fixed b y holding the teeth of both arches in apposition by means of rubber bands until the fracture heals. T h e teeth used should be well seated in the bone and the tension should not be too strong, as single teeth m ay be pulled from their sockets overnight, if the pull is too strong. Loose teeth or those in the line of frac ture should never be utilized in fracture treatment. N o fixed rule is followed as
391
Logsdon— Fractures of M axillae and M andible
regards removal of teeth in the line of fracture or those badly loosened by the injury. Should a fracture occur in the region of the most posterior tooth of the mandible, generally this tooth should not be removed at first, as its presence pre vents the posterior fragment from being displaced upward. A tooth in such a posi tion should be retained for at least three weeks. Then , if necessary, it could be re moved, and doubtless the distal fragment would not be displaced. Should this frag ment be pulled upward, a small splint can be constructed to hold it in normal position. Splints of this type can be used where the arches are wired in apposition. T h e rem oval of all loose teeth in the line of fracture, unless they are badly needed to hold the fragment in position, is indi cated. T h eir retention often results in infection. Elastic tension can also be applied in the treatment of fractures of the maxillae. Following is a case in point: T h e left m axilla was fractured anteroposteriorly. T h e fractured fragm ent was displaced lingually and the teeth of this fragm ent were i cm. lingually from the lower teeth. A n arch bar was ligated to the teeth of the right maxilla. T h e bar extended around the arch to the m olar teeth on the opposite side, about i inch labially and buccally from the teeth of the fractured fragment. Tw enty-gage wires were twisted around three teeth of the frac tured fragm ent and the ends bent to form hooks. Elastic bands were placed over these hooks and the lugs of the arch bar. T h e displaced fragment was pulled into normal occlusion and then the teeth of the fractured region were ligated to the arch bar. T h e upper and lower teeth were then wired in apposition and were held there for four weeks, during which a union was formed. A similar case was reduced by the same procedure. Instead of immobilizing the arches together, the operator used a horseshoe shaped vulcanite splint fitted to the palate to hold the fractured frag
ment in position and allowing movement of the mandible. T h e rubber bands mentioned are made from rubber tubing about one-eighth inch in diameter. It must be flexible and o f a good quality. T h e wires used to ligate the arch bars to the teeth are 25-gage and should be easy to manipulate. Wires used in m aking hooks for pulling and holding purposes should be about 20rgage and rather rigid. T h e wires should be firmly ligated around the teeth and should not impinge on the soft tissues. O pen reduction and other surgical pro cedures are sometimes indicated in fra c ture treatment. Splints of various types and head and chin appliances are also used in treating fractures o f the jaw . Postoperative care should follow reduc tion and fixation of the fractured jaw. It is of paramount importance that ade quate drainage be established and m ain tained in the presence of infection. M ore often than not, extra-oral drainage is in dicated rather than intra-oral. Rubber drains in the form of tubes or strips should be inserted in the incision. T h ey should be changed every twenty-four to fortyeight hours. T h e oral cavity should be kept as clean as is possible during fixation. L un g abscesses and other com plications m ay result from oral sepsis while the arches are wired. Potassium permanganate, 1:3000, for mouth irri gation, is valuable as a cleanser and de odorant, especially in the presence of wires. U N IO N O F F R A C T U R E S
Bony union and normal function w ith out disfigurement are the results desired in the treatment of ja w fractures. Normal occlusion is the criterion in the reduction and fixation of these parts. O nly two ex amples of fibrous union were recorded in nearly 200 patients treated at Hines for fractured mandibles. T h e roentgeno grams taken one year after fixation revealed the absence of bone in the frac tured area. O ne jaw was again roentgen-
392
T h e Journal o f the Am erican D en ta l Association
ographed a year later, but there was no apparent change. Functionally and clinically, fibrous union was in both cases normal. Both patients had tuberculosis. In other patients w ith this disease, frac tures have healed normally. Four pa tients had neither fibrous nor bony union, but each fracture was several weeks old, and treatment had been instituted before the patient was received at Hines, and unusual complications were already pres ent. Fractured jaws should generally be re duced and fixed immediately. H owever, in the presence of severe infection and swelling of the parts, shock and other complications, temporary measures can be applied, in the form of application of head and chin straps, etc.; but reduction and fixation should be accomplished soon after complications have subsided. A type two fracture of the mandible in the area of the mental foram en of five months’ duration, without treatment, was included in the Hines group. By elastic tension, the displaced anterior fragment was pulled into normal posi tion, the procedure requiring about one week. T h e fragments were then fixed and were held there for four months. In the meantime, bony union o f the parts took place. SUM M ARY
N early 200 jaw fractures have been treated at the U. S. Veterans Hospital, Hines, 111., during the past seven and one-half years. About 95 per cent of pa tients in this group were W orld W ar vet erans whose average age at the present time is 46 years. Spanish Am erican W ar veterans, whose average age a t the pres
ent time is 66, constitute the remainder. M ore than 95 per cent of these fractures were of the mandible. T h e mental fora men was the most common area of frac ture, the area at the angle of the ramus ranking second. A m ajority of these fractures were caused by “ slugging.” Injuries from auto mobile accidents were listed as the second cause. Interm axillary wiring, in combi nation with elastic tension, was the method most used in the treatment of these fractures. T h e average time of fix ation was eight weeks, and a large m ajor ity o f these fractures were infected. U nion occurred in all but four instances. T h e fibrous union in two cases mentioned elsewhere is not included among the four cases of non-union. b ib l io g r a p h y
1. A d d i s o n , P. J.: Treatm ent of Non-Union and Loss of Substance in Fracture of Edentu, lous M andible. J.A .D .A ., 25:1081-1084, July
1938. 2. A l b e e , F. H . : Treatm ent of Non-Union with or W ithout Loss of Bone. M il. Surgeon, 78:413-427, June 1936. 3. A u f d e r h e i d e , P. J.: Treatment of Frac tures of M axilla, M andible and Other Bones of Face. J .A .D .A ., 21:950-961, June 1934. 4. B l a ir , V . P.: Surgery and Disease of M outh and Jaws. Ed. 3. St. Louis: C. V . Mosby Company, 1918, pp. 131-145. 5 . G i l k i s o n , C . C .: Treatment of M axillo mandibular Fractures. M il. Surgeon, 8 4 : 4 4 1 4 5 1 , M ay 19 3 9 .
6. G i n g r a s s , R . P.: Early Management of Facial Fractures. J.A .D .A ., 25:693-706, M ay
1938. 7 . G r i m s o n , K . S.: Healing of Fractures of M andible and Zygom a. J.A .D .A ., 24:14581469, September 1937.
8. K a z a n j i a n , V . H . : Treatment of Auto mobile Injuries of Face and Jaws. J.A.D .A.,
2 0 :757 - 772 , M a y 1933.