Some innovations in the field of jaw fracture

SOME INNOVATIONS

IN THE

Otto Neuner, M.D., Innsbruck,

FIELD

OF JAW

FRACTURE

A.ustria

I

N THE treatment of jaw fracture, we distinguish two approaches: (1) immobilization of the jaws and (2) functional treatment. In the first method fixation of the fractured fragments is accomplished by binding the two jaws together and immobilizing the mandible. For this, various wire splints are usually fitted and fixed to the teeth of the patient. Then the two jaws are tied together with wires or intermaxillary elastics. The jaws are left in this position for several weeks until the fracture is comTt would take us too far afield to enter into a pletely and firmly united. discussion of all the advantages and disadvantages of the various methods of intermaxillary fixation. They are generally known to every practitioner who specializes in fracture treatment. The functiotial method seems to have many advantages. Since the fractured jaw alone is immobilized by intraoral or extraoral splints, function of The patient can use the mandible freely and the jaws is but slightly limited. Furtheris not essentially hindered in taking nourishment during treatment. more, the functional performance of the fractured jaw effects a strong inducement to the formation of callus, which shortens the healing time. From the hygienic and biologic standpoint also, the functional treatment is preferable to immobilization, especially in cases of dislocation when it is advisible to start functional treatment as soon as possible. In our clinic we have developed methods for the functional therapy of different types of fractures. Our endeavor has been, above all, to develop simple methods that were the least trying for the patient. TREATMENT

OF

FRACTURES

OF

THE

HORIZONTAL

RAMUS

For these fractures, we employ lingual acrylic splints which are fixed to the teeth by means of buccal contacted acrylic, fortified by a screwable wire To make the splints, impressions of both jaws are taken arch (Fig. 1, A). The ~nodrl distort,ed by the fractured parts is and cast with hard plaster. then set into occlusion and fixetl. Then the splints :IW ulaclc on t,hr model thus obtained.‘” 0.

From Preissecker,

Innsbruck University Director).

Dental

Clinic,

Department

403

of

Maxillo-Facial

Surgery

(Prof.

H.

c.

A, Splint for simple Fig. L-various splints for jaw fractures. C, Mandibular splint with buttons for internmxillary Ax&ion. ttons. (From Neuner: Deutsche Znkn. Ztsck~. lo: 726, 1957.)

Fig.

Z.-Mandibular

fracture.

A,

Before

treatment.

h’, With

fracture Maxillary

splints

of man& Ible. splint \ vith

in ylace.

Volume Number

12 4

INNOVATIONS

IN

FIELD

OF JAW

FRACTURE

405

In order to obtain an exact and close-fitting appliance, it is presumed that all deposits and tartar have first been removed from the teeth. It is also advisable to lightly erase the interdental spaces on the plaster model. In order to insert the appliance, the lingual splint is first pressed with the clasp into its place. Then the screws are put through the loops of the two Since the labial arch lined with acrylic arch parts and are tightened slowly. is quite closely adherent to the teeth, the fragments are held together like a unit in a vice, and a vertical displacement is impossible (Fig. 2). Dislocated fragments are easily positioned by gradual tightening of the screws and by subsequent intermaxillary fixation by means of elastics. This splint can also be employed for the treatment of alveolar fractures as well as immobilization of luxated repositioned teeth by using a removable tension clamp instead of the screw (F’ig. 3). In other cases it may be wise to use an undivided buccal arch whereby the splint has to be inserted under rotating movement. This enables the patient to take off the splint for cleaning and to insert it again.

Fig.

3.-Splint

that

can

be

removed

by

patient.

While the above-mentioned appliance is generally employed as a purely functional prosthetic interdental appliance, it is also possible to apply intermaxillary fixataion of longer duration with similar splints (for instance, after orthodontic operations, in defect fractures, and in certain kinds of fractures in the angle of the ramus or of the ascending ramus). In such cases, several acrylic buttons or wire hooks are fixed to the buccal arch (Fig. 1, B and C). The advantages of the described splint arc as follows: 1. The splint is retained without wire ligatures, screw bands, or cementing. 2. The insertion and removal are very simple and require little time. 3. Since the gingival edge is left free of acrylic, the patient can easily clean the teeth by means of a toothbrush. 4. The masticating surfaces remain uncovered, so that the occlusion can be constantly checked during treatment. 5. The splint is constructed in the technical laboratory, and therefore the patient is spared time and discomfort.

406

0 s., 0. RI. 610. P. April. I9)i’,

NE:LJNER

FRACTURES

OF THE

LOWER

JA\V

WHEP;

MOLARS

OR PREMOLARS

ARE ABSENT

In these fractures the dental prost,hesis has to be built out over the edentulous area to provide some func+ion as a prosthesis. If a sufficient number of teeth in the front area are available, these are employed for retention of the splint. It is important that the free-end saddle reach some centimeters beyond the fracture, a.nd it is fixetl to the tdentulous lower jaw fra.gment Iti completely eclcntulous patients by means of circumferential suturing. complete acrylic dentures arc nlwtle autl fa,stenetl OII both sides of the jaw by circumferential suturing. IXvcn if transosscous wire sutures arc used a prosthet*ic appliance must still bc made in addition. for the wire sut,urc alone produces no effective intcrmasillary fixation of the fragments. FRACTURES

IX

THE

.\RE:\

01: THE

ANGLJ’:

OF TIHE: J.\\V

For fractures of this kind, if there is no tlisplacemcnt, intermaxillar> fixation of the jaw 1)~ means of the chin cap is often sufficient, for the muscle sling of the intcrnwl ptcrygoitl ant1 th(, Irlassctcr reprc>scnts sufficient fixatiotl.

A Fig.

4.-Extraoral

R. appliance

for

splinting

fractures

at

the

angle

of

the

jaw.

If there arc atlditional fractures in the tooth-bearing part which make th(l use of a splint necessary, WC establish an extension from the splint to fix the posterior fragment in position. If, however, the dislocation of the fragments is more severe, t,he fracture must bc reduced by temporary intermaxilla.ry fixation. It then may be fixed by employing an extraoral appliance developed by us. It is a type of clamp with two pointed prongs, the points of which are directed inward. One prong of this applicance is fixed into a previously drilled hole at the lower edge of the horizontal ramus, the other l)rotlg is fixed into a similar hole ma& in the posterior edge of the ascending ramus. The holes are drilled IIII(IC’Y local anesthesia. By means of a screw device, the I’ragments can be prcsst>cl together firtllly zrncl fastened in this position (Fig. fixation, a chin-cap banclagc can bc 1). In addition to this intermaxillary worn for some time. 1:esidrs this extraoral fixation, we have lately employetl

Volume 12 Number 4

INNOVATION8

IN

FlRI,I)

OF

.JA\V

407

E’l:ACTI!l:E:

with good results a screw clamp which is set directly from an intraoral approach t,o the bone of the ascending right ramus and then fastened by means of an arch wire perforating the mucous membrane t.o the toobh system itself or to one of the splint,s, if such are c~lployed (Fig. 5). FRACTURES

OF THE

ASCENDING

RAMUS

AND

FR.ZCTURES

OF THE

CONDYLE

Functional treatment of these fractures is very important except in cases of open fracture. If normal position of the occlusion cannot be obtained by using a chin cap, we content ourselrcs with intermaxillary elastics applied for a short duration, after which, when normal occlusion hn.s been obtained, we change to inte~,nlnxilla~~y fixation by means of a chin cap.

B. Fig.

5.--Intraoral

clamp

on ascending

ramus

for

splinting

fractures

at

the

angle

of the

jaw.

In cases of dislocations associated with concomitant fracture in another part of the mandible, it is necessary to apply a splint for the mandibular fractures. In the case of existing dentures, we reduce the dislocation by employing

NET-NFX

408

0. S., 0. M. & 0. P. April,

1959

inclined planes (Fig. 6). Frequently, however, we just immobilize the jaw with a chin cap and advise the patient to masticate only on the healthy side and to eat only soft food, of course. In order to obtain normal occlusion in verGea displacement of the ramus fragments, it is advisable to raise the bitt in the molar area by means of an acrylic bite plate and the use of intermaxillary elastics on the anterior teeth. d

I3. Fig. B.-Multiple fractures of horizontal ramus and articular process of left mandible. B, Normal A. Malocclusion resulting after splinting of the fracture in the horizontal part. occlusion obtained by use of inclined surfaces attached to the splints and use of a chin strap.

As soon as normal occlusion has been obtained, a chin cap is used for immobilization. It is important, however, that in all cases of fractures in the area of the condyle, a lengthy period of immobiIization of the temporomaxillary joint must be avoided, as it is known from experience that after prolonged immobilization such functional disturbances as temporary closure of the jaw, ankylosis, etc., may develop. If they occur, they should be corrected by immediate functional therapy. ALVEOLAR

FRACTURES

IN

THE

UPPER

JAW

These are treated with splints which are similar to those described for the mandible, except that the palatal part consists of a plate (Fig. 1, C).

INNOVATLONS

%%r’f

TN FIELD

OF JAW

409

FRACTIIHE

An existing displacement is reduced either by finger pressure or by forcible intercuspidation of the fragments under anesthesia. The dislocated fragment is grasped with bone forceps and forced out of its overlapping position by hard outward and inward movements. A split plate provided with a screw, which permits the repositioning of the fragments by orthodontic procedures, may be used. SAGITTAL

FRACTURES

OF THE

MAX1LL.Z

We treat sagittal fractures with plates containing a built-in regulating screw between the two parts (Fig. 7). From each plate projects an arch, which encircles the side teebh. These arches are made of 0.9 to 1 mm. strong hard steel wires, which are enforced with acrylic so as to be well fitted to the buccal sides of the respective teeth. With this appliance, repositioning as well as good retention of the fragment,s can be guaranteed by tightening the screw.

Fig.

7.-Maxillary

HORIZONTAL

splint

FRACTURES

for

treatment

A?;D

of

EXTENSIVE

sagittal position. DAMAGE

fractures

OF THE

with

orthodontic

screw

in

open

MAXILLA

In these cases the maxilla is often displaced backward, downward, or to the side. In order to reduce them, we use an intermaxillary extension device which, in principle, resembles the horizontal extension stay used by Wassmund.” This device is shown in Fig. 8. In cases of new fractures (and those not older than two or three weeks) situated in the molar area of the maxilla, the side teeth or canines, we attach one or several wire ligatures to the teeth with one sling to each. In the mandible acrylic splints arc made which vary from the ones employed for horizontal ramus fractures only in that the buccal arch is turned and has no screw. From the middle of the arch there is projected a horizontal extension bar to the front which has a hook at its anterior end. To this hook are fastened elastics, which pull the upper jaw in a horizontal direction from the lower to the upper jaw. The reduction is aided by the movement of the lower jaw. With this method we obtain a good result in a short time, even

NEUNER

410

0. S., 0. M. & 0. P. April,

1919

in cases of wedged-in fragments, by pullin g the upper jaw forward and reLateral displacement can be corrected by establishing normal occlusion. tightening the intermaxillary elastics on the respective sides. Even 2- or 3month-old fractures, in which treatment has been postponed because of more

A.

B.

c.

Fig.

R.-Appliances and

for reposition lower jaws.

of the posteriorly displaced maxilla. B, Appliance on model. C, Appliance

A, Splints in situ.

for

upper

dangerous injuries and which may already have consolidated, can still be repositioned satisfactorily in this way. Since great strength is needed in such old cases, it would be of adva,ntage to make a plate for the maxilla with an arch made of 1 mm. hard steel wire with some slings to attach the elastics. In this way, the stress is divided equally among all teeth. If the arch alone is not sufficient to retain the plat,e, the latter is fixed on both sides to

Volume Number

12

4

INNOVATION8

IN

FIELD

OF JAW

FRACTURE

411

one or several teeth by means of wire ligatures (0.2 mm. steel wire). If there are addit.ional sagittal or alveolar fractures in the upper jaw, or loosened teeth, a buccal passing arch is employed. The intermaxillary extension method described has proved essentially better than the extraoral appliances formerly employed by us, which included a plaster skull cap which, because of the usually present postcommotional symptoms (headache, concussion of the brain, dizziness, etc.), is often not well tolerated by the patient. Furthermore, in eases of old, long-existing, badly impacted fractures which necessitate the use of strong pull, the head bandage is pulled downward in front. This requires a counterpull in the neck, which is extremely disagreeable to the patient. The method described permits continued fixation of the maxilla after the normal occlusion has been attained. This is particularly important in old fra.ctures which have a tendency to return to the displaced position. During the last two or three weeks the elastic pulls must be gradually decreased and finally temporarily removed. Only if no t,endency to renewed displacement is evident should the appliance be taken out. Further protection from redisplacement may be obtained by means of a chin cap. The advantages of this method are as follows: 1. Simplicity of construction and application of appliance. 2. Patient can freely move his mandible, which permits unhindered mastication and oral hygiene. 3. Elimination of the use of extraoral appliances (head bandage, plaster skull cap, or weight extension), although in cases of downward dislocations a chin-cap bandage may have to be used to reposition the maxilla and in cases of a completely mobile upper jaw fragment, loosely hanging in the soft parts, we must also use in addition extraoral splints. It is not the purpose of this article, however, to describe the construction and application of the latter. CONCLUSION

In the treatment of jaw fractures, functional treatment is preferable to immobilization of the jaws. I have been engaged for some years in the treatment of jaw fractures and have developed methods which permit excellent A splint is described for the functional repair in various kinds of fractures. treatment of fractures in the tooth-bearing mandibular area and, in modified form, of alveolar fractures in the upper and lower jaws, for upper sagittal fractures and for fixation of loosened teeth. For fractures in the area of the angle of the jaw, an extra,oral and intraoral appliance is described. Fractures of the condyle and fractures in t,he ascending ramus are in most. instances treated functionally after attaining normal occlusion. For maxillary fractures with lateral or dorsal dislocation, an intermaxillary extension appliance has been used successfully for the repositioning and fixation of fresh fractures as well as fractures partly united in malposition because of delayed treatment.

NEUNEE

41%

0. s.. 0. .%I.&I0. P. April, 1959

RYBERENCES 1 1. Archer, W. H.: A hlanual of Oral Surgery, Philadelphia autl London, 1953 and 1954, W. B. Saunders Company. 2. Axhausen, G.: Leitfaden der zahnlretlichen Chirurgie, Miinehen, 1950, Carl Hanser. Chirurgische Operationslehre, vol. 2, 3. Brosch, I?.: In Bier, Braun, and Kiimmel: Leipzig, 1954, Johann Ambrosius Barth. Chirurgie de la face, Paris, 1952, Masson 4. Dufourmentel, L. : In Aubry and Freidel: & Cie. Chirurgie des Kopfes, Berlin, 1953, W. de Gruyter. 5. Klose, H., and Gruntlmann, h.: 6. Kahler, J. A.: Diagnostik und Therapie der Kieferfrakturen, Heidelberg, 1951, Hiithig. Johann Amhrosius 7. Kranz, P. P.: Chirurgie des praktischen Zahuarztes, I,eipzig, 1957, Barth. Surgery of Face, Jlouth and Jaws, 3. McDowell, E’., Brown, J. B., and Fryer, M. P.: St. IIouis, 1954, The (>. V. Mosby Company. 9. Meyer, W.: In Zillmer: Kriegschirnrgie, Dresdeu and J,eipzig, 1943, SteiukopfJ. 10. Neuner, 0.: Deutsche Zahn. Ztschr. 10: 726, 195i. 11. Obwegeser, H.: Schweiz. Monatschr. f. Zahnh. 4: 328, I95.5. 12. Pichler, H., and Trauner, R.: Lehrbuch der Muncl- untl Kieferchirurgie, Band 1 Wien, 1946, Urban & Schwarzenberg. 13. Reichenbach, E.: Leitfaden der Kieferbruchbehandlung, ed. 6, Leipzig, 1954, Johann Ambrosius Barth. 14. Reichenbach, E.: In Biirkle de la Camp, H., and Restock, Y.: Handbuch der gesamten Unfallheilkunde Band 2, Stuttgart, 1955, Ferdinand Enke. 15. Reichenbach, E.: In Hjdupl, K., Meyer, W., and Schuchardt, K.: Die Zahn- Mund u. Kiefer-Heilkunde, Band 3, Mtinchen, 1957, Urban & Schwarzenberg. 16. Ritter, R.: In Port and Euler: Lehrbuch dor Zahnheilkunde, Miinchen, 1951, .T. 1”. Bergmann. 17. Ritter, R.: In Kirschner: Allgemeine und spezielle chirurgische Operationslehre, 1956, Julius Springer. Band 4, Berlin, Gb;ttingen, Heidelberg, IS. Rowe, N. L., and Killey, H. (:.: Fractures of the Facial Skeleton, Edinburgh, 1955, E. & 8. Livingston?, 1,td. 19. Schuchardt, K., and Waxsmund, M.: Fortschritte der Qesichts- und Kiefer-(:hirurgie, Band 2, Stuttgart, 1956, Georg Thieme. 20. Thoma, K. H.: Ora, Surgery, St. Louis, 1948 and 1958, The C. Y. Moubv Company. 21. Wassmund, M.: Frakturen und Luxationen des Gesichtsschldels, Berlin. 1927. Herntantl Meusser. 22. Wassmund, M.: DcJutsrhe Z&n-. Muncl-, u. Kieferh. 26: 9-10, 346, 1957. SNICHS~K. 35.