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Reduction and immobilization of fractured maxilla by weight traction
REDUCTION
AND RKMOBILIZATION OF FRACTURED BY WEIGHT TRACTION
MAXILLA
Reports of Cases CONRAD
SPILKA,
D.D.S.,”
CLEVELAND,
OHIO
F
RACTURES 0 the maxilla are frequently the result of automobile accidents. The driver or rider is thrown forward striking his face against the instrument panel or steering wheel. These fractures should be reduced as soon as possible since any undue delay complicates the fracture as well as makes the The use of weight traction is recommended. reduction of it more difficult. Case Reports Case l.History.-D. W., a woman, aged 30, seen April 1, 1947, was injured in an automobile accident, suffering multiple facial injuries. She was given first aid in a lotial hospital and transferred to Crile Veterans Administration Hospital for definitive treatment.
Physical Examination.-Physical examination revealed considerable facial swelling and ecchymosis of the infraorbital region bilaterally. Intraoral examination revealed the anterior maxilla to be pushed backward from cuspid to cuspid. The upper left central incisor had been broken out and the upper left lateral incisor broken loose. The upper right central incisor was fractured through the incisal third. The remaining maxillary anterior teeth were pushed to the lingual of the lower anterior teeth. The buccal mucosa was badly lacerated and the hard palate deeply perforated in the anterior region. All of the upper and lower posterior teeth were missing. There was no evidence of injury to the mandible. Blood and urine studies were negative. Roentgenographic Examination.-Roentgenograms revealed a comminuted vertical fracture of the anterior portion of the hard palate with upward and backward displacement (Pigs. 1 and 2). Treatment.-The patient was given 50,000 units of penicillin hours. The pain was controlled with codeine sulfate.
every three
Operation.-On April 5, 194’7, the patient was taken to surgery for the manipulation and reduction of the fractured maxilla. Under local anesthesia, Jelenko splints were wired to both the upper and lower jaws before reduction was attempted. With a forceps, the right side of the maxilla was elevated and the right component brought into normal position. Because the left component was impacted, it was impossible to bring the remaining teeth into good This paper was reviewed in the Veterans Administration and published with the apm-oval of the Chief Medical Director. The statements and conclusions published by the author are the results of his own study and do not necessarily reflect the oDinion or policy of the Veterans Administration. *Chief, Oral Surgery Section, Dental Service, Veterans Administration Hospital (Crile), Cleveland, Ohio. 1497
1498
CONRAD SPILKA
Fig.
I.--Preoperative
lateral
roentgenogram showing depression maxillary bone in its anterior third.
Fig.
Z.-Preoperative
posteroanterior
roentgenogram backward.
showing
and
maxilla
complete
depressed
fractUN ! of
upward
and
REDUCTION
Fig.
AND IMMOBILIZATION
3I.-Photograph
Fig.
4.-Full
showing
view
attachment
showing
OF FRACTURED
of weight
application
traction
of weight
1499
MAXILLA
to upper
traction.
splint.
1500
CONRAD
SPILKA
occlusion; the mobilization was regarded as sufficient t.o enable this to be effected by weight traction. Elastic traction was used to hold the right component in position and the patient. was returned t,o the ward. On the following day, a Balkan frame was placed on the patient’s bed. h’orward traction was applied by a cord attached to the upper splint in the region of the upper left cuspid, to the end of which a small receptacle containing a I/-pound da.y, this weight was weight, was attached (Figs. 3 and 4). The following increased to three pounds by adding srnall lead pellets at three-hour intervals.
Fig.
Fig.
B.-Postoperative
6.-I’oatoperative
roentgenogram
photograph
and
taken callus
MW
after
removal
27. 1947, formation.
showing
of
splints.
alignment
of
fragments
On the fourth day, the upper jaw had been brought forward with a total Intermaxillary fixation was weight of five pounds and was in good position. by elastic traction. The weight was gradually reduced on the fifth day and removed on the sixth day.
REDUCTION
AND IMMOBILIZATION
OF FRACTURED
1501
MAXILLA
Postoperative Treatment.--On May 6, 194’7, the elastic traction and splints were removed. The teeth were in good occlusion (Fig. 5). Roentgenograms taken May 27, 1947, revealed callus formation. The fracture line of the anterior-superior aspect of the palate was hardly discernible (Fig. 6). Roentgenograms taken June 13, 1947, revealed the fracture line to be obliterated (Fig. 7). The perforation of the hard palate had completely healed. The remaining upper and lower teeth were extracted June 10, 1947.
Fig.
7.-Roentgenogram
taken June 13, 1947, forty-three days after lower teeth extracted June 10. 1947).
reduction
(upper
and
Case 2.History.-J. P., a 26-year-old man, was driving when he lost control of his car May 31, 1948. The car struck a tree, throwing the patient forward and striking his face against the steering wheel. He was given emergency treatment at a local hospital where the right eye was evulsed. On June 18, 1948, when the patient’s condition permitted, he was transferred to Crile Veterans Administration Hospital for further treatment. Physical Examination.-There was considerable facial swelling and ecchymosis. The upper lip was swollen and the mucous membrane lacerated. The bridge of the nose was lacerated and depressed. There was blindness in the left eye. The upper jaw was movable with an upward and backward displacement (Fig. 8). The molar teeth were the only ones that occluded causing an open-bite. The vertical dimension of the face was shortened. Roentgenographic Examination .-Roentgenographic examination revealed a vertical fracture through the posterior third of the hard palate and a horizontal fracture through the maxilla. There was also a fracture through the
1502
COSRAD
neck of the right negative.
SPILKA
condyle of the mandible
(Fig. 9j.
X-ra.ys of the chest were
Treatment.-The patient was given 50,000 units of penicillin hours. The pain was controlled with codeine sulfate.
Fig.
B.-Preoperative
photograph
Fig.
I).-Preoperative
roentgenogram
showing with
showing of the
upward and open-bite.
fracture mandible.
of
backward
maxilla
every three
displacement
and
neck
of
of
right
maxilla
condyle
Operation.-Because of the time which had elapsed since the accident, it was decided that reduction by weight traction would be the most effective treatment. On June 19, 1948, Jelenko splints were wired to the upper and
REDUCTION
Fig.
lO.-Photograph
Fig. 11. Fig. Il.-Postoperative Fig. 12.-Postoperative
AND IMMOBILIZATION
showing
application
OB FRACTURED
of weight
traction
1503
MAXLLA
on Balkan
Fig. 12. photograph showing reduced maxilla and normal roentgenogram showing bone formation.
frame.
occlusion.
1504
CONRAD
SPILKA
lower jaws. A Balkan frame was placed on the patient’s bed. Forward traction was applied by a cord attached to the upper splint in the region of the upper cent’ral incisors so that the fragment could be disengaged with an even pull. A small receptacle containing a l,b-pound weight was attached to the other end of the cord (Fig. 10). Small lead pellets were added every three hours and on the fifth day, under a total weight of six pounds, the masilla was brought forward into its normal position. Jntermaxillary wires were used to hold the jaws in position. The weights were gradually reduced and on the eighth day they were removed.
Postoperative Treatment.-On ,luly 26, 1948, the intermaxillary wires and ,Jelenko splints were removed. The teeth were in excellent occlusion and the patient had a, good functioning jaw (Fig. 11). The patient was sent home to return at a later date for a rhinoplasty. On Feb. 10, 1949, the patient returned for follow-up x-rays. These revealed good approximation of the fragments, with bone formation (Fig. 12). Conclusion The use of traction applied by means of a Balkan frame for the reduction of displaced maxillary fractures has been described. Two case reports illustrate the use of this method.
AND RKMOBILIZATION OF FRACTURED BY WEIGHT TRACTION
MAXILLA
Reports of Cases CONRAD
SPILKA,
D.D.S.,”
CLEVELAND,
OHIO
F
RACTURES 0 the maxilla are frequently the result of automobile accidents. The driver or rider is thrown forward striking his face against the instrument panel or steering wheel. These fractures should be reduced as soon as possible since any undue delay complicates the fracture as well as makes the The use of weight traction is recommended. reduction of it more difficult. Case Reports Case l.History.-D. W., a woman, aged 30, seen April 1, 1947, was injured in an automobile accident, suffering multiple facial injuries. She was given first aid in a lotial hospital and transferred to Crile Veterans Administration Hospital for definitive treatment.
Physical Examination.-Physical examination revealed considerable facial swelling and ecchymosis of the infraorbital region bilaterally. Intraoral examination revealed the anterior maxilla to be pushed backward from cuspid to cuspid. The upper left central incisor had been broken out and the upper left lateral incisor broken loose. The upper right central incisor was fractured through the incisal third. The remaining maxillary anterior teeth were pushed to the lingual of the lower anterior teeth. The buccal mucosa was badly lacerated and the hard palate deeply perforated in the anterior region. All of the upper and lower posterior teeth were missing. There was no evidence of injury to the mandible. Blood and urine studies were negative. Roentgenographic Examination.-Roentgenograms revealed a comminuted vertical fracture of the anterior portion of the hard palate with upward and backward displacement (Pigs. 1 and 2). Treatment.-The patient was given 50,000 units of penicillin hours. The pain was controlled with codeine sulfate.
every three
Operation.-On April 5, 194’7, the patient was taken to surgery for the manipulation and reduction of the fractured maxilla. Under local anesthesia, Jelenko splints were wired to both the upper and lower jaws before reduction was attempted. With a forceps, the right side of the maxilla was elevated and the right component brought into normal position. Because the left component was impacted, it was impossible to bring the remaining teeth into good This paper was reviewed in the Veterans Administration and published with the apm-oval of the Chief Medical Director. The statements and conclusions published by the author are the results of his own study and do not necessarily reflect the oDinion or policy of the Veterans Administration. *Chief, Oral Surgery Section, Dental Service, Veterans Administration Hospital (Crile), Cleveland, Ohio. 1497
1498
CONRAD SPILKA
Fig.
I.--Preoperative
lateral
roentgenogram showing depression maxillary bone in its anterior third.
Fig.
Z.-Preoperative
posteroanterior
roentgenogram backward.
showing
and
maxilla
complete
depressed
fractUN ! of
upward
and
REDUCTION
Fig.
AND IMMOBILIZATION
3I.-Photograph
Fig.
4.-Full
showing
view
attachment
showing
OF FRACTURED
of weight
application
traction
of weight
1499
MAXILLA
to upper
traction.
splint.
1500
CONRAD
SPILKA
occlusion; the mobilization was regarded as sufficient t.o enable this to be effected by weight traction. Elastic traction was used to hold the right component in position and the patient. was returned t,o the ward. On the following day, a Balkan frame was placed on the patient’s bed. h’orward traction was applied by a cord attached to the upper splint in the region of the upper left cuspid, to the end of which a small receptacle containing a I/-pound da.y, this weight was weight, was attached (Figs. 3 and 4). The following increased to three pounds by adding srnall lead pellets at three-hour intervals.
Fig.
Fig.
B.-Postoperative
6.-I’oatoperative
roentgenogram
photograph
and
taken callus
MW
after
removal
27. 1947, formation.
showing
of
splints.
alignment
of
fragments
On the fourth day, the upper jaw had been brought forward with a total Intermaxillary fixation was weight of five pounds and was in good position. by elastic traction. The weight was gradually reduced on the fifth day and removed on the sixth day.
REDUCTION
AND IMMOBILIZATION
OF FRACTURED
1501
MAXILLA
Postoperative Treatment.--On May 6, 194’7, the elastic traction and splints were removed. The teeth were in good occlusion (Fig. 5). Roentgenograms taken May 27, 1947, revealed callus formation. The fracture line of the anterior-superior aspect of the palate was hardly discernible (Fig. 6). Roentgenograms taken June 13, 1947, revealed the fracture line to be obliterated (Fig. 7). The perforation of the hard palate had completely healed. The remaining upper and lower teeth were extracted June 10, 1947.
Fig.
7.-Roentgenogram
taken June 13, 1947, forty-three days after lower teeth extracted June 10. 1947).
reduction
(upper
and
Case 2.History.-J. P., a 26-year-old man, was driving when he lost control of his car May 31, 1948. The car struck a tree, throwing the patient forward and striking his face against the steering wheel. He was given emergency treatment at a local hospital where the right eye was evulsed. On June 18, 1948, when the patient’s condition permitted, he was transferred to Crile Veterans Administration Hospital for further treatment. Physical Examination.-There was considerable facial swelling and ecchymosis. The upper lip was swollen and the mucous membrane lacerated. The bridge of the nose was lacerated and depressed. There was blindness in the left eye. The upper jaw was movable with an upward and backward displacement (Fig. 8). The molar teeth were the only ones that occluded causing an open-bite. The vertical dimension of the face was shortened. Roentgenographic Examination .-Roentgenographic examination revealed a vertical fracture through the posterior third of the hard palate and a horizontal fracture through the maxilla. There was also a fracture through the
1502
COSRAD
neck of the right negative.
SPILKA
condyle of the mandible
(Fig. 9j.
X-ra.ys of the chest were
Treatment.-The patient was given 50,000 units of penicillin hours. The pain was controlled with codeine sulfate.
Fig.
B.-Preoperative
photograph
Fig.
I).-Preoperative
roentgenogram
showing with
showing of the
upward and open-bite.
fracture mandible.
of
backward
maxilla
every three
displacement
and
neck
of
of
right
maxilla
condyle
Operation.-Because of the time which had elapsed since the accident, it was decided that reduction by weight traction would be the most effective treatment. On June 19, 1948, Jelenko splints were wired to the upper and
REDUCTION
Fig.
lO.-Photograph
Fig. 11. Fig. Il.-Postoperative Fig. 12.-Postoperative
AND IMMOBILIZATION
showing
application
OB FRACTURED
of weight
traction
1503
MAXLLA
on Balkan
Fig. 12. photograph showing reduced maxilla and normal roentgenogram showing bone formation.
frame.
occlusion.
1504
CONRAD
SPILKA
lower jaws. A Balkan frame was placed on the patient’s bed. Forward traction was applied by a cord attached to the upper splint in the region of the upper cent’ral incisors so that the fragment could be disengaged with an even pull. A small receptacle containing a l,b-pound weight was attached to the other end of the cord (Fig. 10). Small lead pellets were added every three hours and on the fifth day, under a total weight of six pounds, the masilla was brought forward into its normal position. Jntermaxillary wires were used to hold the jaws in position. The weights were gradually reduced and on the eighth day they were removed.
Postoperative Treatment.-On ,luly 26, 1948, the intermaxillary wires and ,Jelenko splints were removed. The teeth were in excellent occlusion and the patient had a, good functioning jaw (Fig. 11). The patient was sent home to return at a later date for a rhinoplasty. On Feb. 10, 1949, the patient returned for follow-up x-rays. These revealed good approximation of the fragments, with bone formation (Fig. 12). Conclusion The use of traction applied by means of a Balkan frame for the reduction of displaced maxillary fractures has been described. Two case reports illustrate the use of this method.