- Email: [email protected]
Treatment of Fractures of the Upper Jaw
E r ic h — F r a c t u r e s
tion of each patient. T h e dental profes sion has a great responsibility, and we must meet it. It is our obligation to be fair and honest with the public. I am afraid that we are prone to forget some of these obligations. T h e “ Doctor” be
of
U
pper
Jaw
783
fore our names means a great deal more to the public than we at times realize. So let us be careful to uphold the title that we bear, and make the public feel that it can put its trust in us. Medical Arts Building.
TREATMENT OF FRACTURES OF THE UPPER JA W By
John
B.
E r ic h ,
D .D .S., M .D ., Rochester, Minn.
R O M the standpoint of therapy, no injuries affecting the bones of the face offer more intricate problems than do fractures of the upper jaw. The treatment of any fractures of the jaw has two objectives: first, reduction of the fracture in a manner not only to replace the fragments in their original position, but also to restore the teeth to normal occlusion; and, second, immobilization that will lead to a strong bony union of the fragments. In a case o f fracture of the maxilla, the selection of the method or methods best adapted to attain both of these objectives requires a great deal of preoperative planning and frequently the preparation of rather elaborate ap pliances. Extremely helpful in determin ing the treatment most suitable in an individual case is a comprehensive knowledge of present-day operative pro cedures. Although a review o f these procedures as described in the literature is both instructive and interesting, it also is likely to be somewhat confusing. One finds that different opinions are enter tained in regard to the treatment of vari ous types of fractures of the upper jaw,
F
From the Section on Laryngology, Oral and Plastic Surgery, The Mayo Clinic, Read before the Section on Oral Surgery, Exodontia and Anesthesia at the Eighty-Third Annual Meeting of the American Dental As sociation, Houston, Texas, October 30, 1941. Jour. A .D .A., V ol. 29, M ay 1942
opinions which are indeed often com pletely contradictory. T h e explanation of this situation rests in part on personal prejudice and par tiality that prevent a proper estimation of the merits of various procedures. Then too, some methods described in detail in the literature deal not with the general, but with a particular, case. Moreover, every surgeon, through his own natural qualities, has instinctive methods of operating. A technic which is most effi cient when applied by one operator m ay be rather unsatisfactory in the hands of another. Consequently, in considering fractures of the upper jaw, one cannot insist that his methods are superior to all others, but can merely present those procedures which in his experience have given the most effective results. T h e treatment o f any fractured jaw is successful only when the continuity of the bone has been established and the normal masticatory mechanism has been restored. T h e fragments of a fractured jaw m ay heal firmly by bony union, but the end-result is a failure if the original occlusion of the teeth has not been re established, to insure normal mastication. Nearly every fracture of a jaw in which there is the least displacement of the fragments causes some disturbance of occlusion, and unless the teeth can be brought into normal relationship, the
784
T
he
Journal
of th e
A
m e r ic a n
fragments will not be restored to their original position. Nothing serves as a better guide to the proper position of the fragments than does the occlusion of the teeth. Frequently, in cases o f frac ture o f the jaws, it is almost impossible to. determine by visual inspection o f the mouth w hat relationship actually existed between the upper and lower teeth be fore the fracture occurred. This m ay be the result o f the loss o f m any teeth in each dental arch or it m ay be due to primary malocclusion of the teeth. C on sequently, the preparation o f plaster study models of the dental arches will aid materially in determination of the original occlusion. In general, then, the treatment of fractures of the upper jaw should be deferred not only until maxillodental
D
ental
A
s s o c ia t io n
vention of an abscess and possible osteo myelitis. As a matter of convenience in discuss ing the therapeutic management o f frac tures of the upper jaw, I have found it advantageous to classify such fractures in four groups : (1) fractures which pro duce a complete separation of the upper jaw from the rest of the skull, (2) trans verse fractures o f the m axilla associated with one or more fractures of the palate, (3) unilateral fractures o f the upper jaw and (4) simple fractures of the upper alveolar process. (Fig. 1.) fractu res
c a u s in g
a
com plete
separa
t io n o f t h e u p p e r j a w f r o m t h e rest of th e sk u l l
It is advisable to consider three forms of fractures which produce complete
Fig. 1.— Fractures which produce complete separation of upper jaw from remainder of the skull, a, transverse maxillary fracture, b, pyramidal facial fracture, c, transverse facial fracture.
roentgenograms can be secured, but also until plaster study models can be pre pared. O n ly with such accessory diag nostic agencies can one accurately deter mine the best method o f reducing the fracture and of immobilizing the frag ments. Prior to the actual reduction of the fracture, débris and loose pieces of bone, which unquestionably would form sequestra, should be removed. Further more, I wish to stress the importance of extracting every tooth the root of which is exposed in a line of fracture unless the tooth is absolutely necessary for the fix ation of a bony fragment. In m y ex perience, the removal o f such teeth is an extremely important step in the pre
separation of the maxillae from the rest of the skull. As illustrated in Figure 1, the first and most common type is the horizontal or transverse fracture o f the upper jaw in which the greater portion of the m axilla is detached as a free seg ment. T h e second type, not infrequently encountered, is the pyram idal facial fracture (so-called because it assumes the form o f a pyramid) which extends up ward through each antrum to the eth moid region and base of the nose. In this form, the loose fragment is composed of the entire m axillae and the nasal bones. Pyramidal facial fractures are often associated with a depressed or com minuted fracture of one malar bone. O f
E r ic h — F r a c t u r e s o f U p p e r J a w
rare occurrence is the third type, which may be described as a transverse facial fracture passing through the base of the nasal and ethmoid regions and across the orbits to the zygomatic arches. This fracture is of such character that the upper jaw, m alar and nasal bones con stitute one complete displaced structure. As would be expected, the last type of fracture is extremely uncommon because it almost invariably is present in con junction with depressed fractures of both malar bones, and, under such circum stances, the facial injury actually is con verted into a combination of a pyramidal facial and a transverse facial fracture. One should not overlook the fact that
7^5
ture, there is a tendency for the upper jaw to be forced upward and backward with a resultant open-bite type of de formity. Pyramidal facial and transverse facial fractures, on the other hand, are likely to cause a downward displacement o f the upper jaw with varying degrees o f malposition between the upper dental arch and the lower teeth. In such in stances, roentgenograms frequently re veal a space several millimeters in width between the upper border of the 'nasal bones and the glabella portion of the frontal bone, and there is frequently an associated fracture o f the cribriform plate of the ethmoid bone. It is not un common, in cases of fractures of the
Fig. 2.— a, multiple fractures of facial bones including transverse maxillary fracture, pyra midal facial fracture and transverse facial fracture, b, fractures reduced and immobilized.
two or all three of these fractures m ay exist together in the same patient. (Fig. 2.) M oreover, fractures o f the malar, nasal and ethmoid bones are frequently encountered in connection with severe fracture of the upper jaws. A lthough the three fractures which have been described possess definite an atomic differences, the objective intra oral findings are often indistinguishable. Clinically, the upper jaw is loose and movable and more or less displaced so that the teeth do not occlude properly. However, in a transverse m axillary frac-
ethmoid bone, to find that cerebrospinal fluid drains from the nose for several days following the injury. Since cerebro spinal rhinorrhea is a sign of serious bony trauma in the ethmoid region and re quires specific therapeutic management, its recognition in all cases of severe in jury to the upper ja w or to the nose cannot be stressed too strongly. In spite of the fact that the thera peutic management of the three types o f fractures under consideration is essen tially the same, their early clinical recog nition through roentgenographic studies
786
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
is distinctly advantageous. By determin ing which one or combination of these fractures exists in each individual case, one can predict with a fair degree of accuracy the difficulty which will be encountered in the reduction of the frac ture. In cases of pyramidal or a trans verse facial fracture, reduction is usually a much more difficult task than in cases of a simple transverse m axillary fracture.
moid bone, a complication that m ay lead to a fatal meningitis. In treating fractures of the upper jaw associated with fracture o f the cribriform plate of the ethmoid bone, any injury o f the overlying soft tissues o f the face should, I believe, be taken care of as soon after the injury as is feasible. H ow ever, it is extremely important not to treat the fractured facial bones for from
Fig. 3.— Reduction and immobilization of pyramidal facial fracture, a, traction with rubber bands bringing teeth into normal occlusion, b, turnbuckles attached to traction wires and hooks on head cast elevating loose fragment of bone; adjustable hooks on head cast preventing un necessary scarring of cheeks, c, pyramidal facial fracture immobilized by traction wires through cheeks.
Furthermore, the preoperative diagnosis of the type of fracture present is of value in ascertaining the gravity of the injury, since fractures of the second and third type are frequently associated with frac ture of the cribriform plate of the eth-
ten to fourteen days after the injury because any manipulation of these bones m ay disturb the fracture o f the ethmoid bone and induce meningitis. A fter this length of time, the fracture in the eth moid region has become walled off to a
E r ic h — F r a c t u r e s
certain extent by fibrous tissue, and it is then safe to proceed with whatever measures are necessary to reduce and im mobilize the fractured bones of the face. During the interval of from ten to four teen days, it is well to give the patient one of the sulfonamide preparations as an aid in the prevention of meningitis. As applies to all fractures, the treat ment of injuries of the facial bone which are associated with a complete separation o f the upper jaw from the rest o f the skull consists first in reduction and later in immobilization of the parts involved. T h e reduction of these fractures, in gen eral, is based upon mechanical appli-
of
U
pper
Jaw
787
proper position, whereas the ultimate result would be more or less o f a failure if one attempted m anually to replace the fractured m axillae in accurate alinement. T h e reduction by elastic traction of the three types o f m axillary fracture under consideration requires, first, the application to the upper dental arch of a hooked arch bar, which is wired securely to each upper tooth. (Fig. 3.) Next, a similar arch bar is wired to the teeth of the lower jaw . T h en rubber bands stretched between the hooks of the up per and lower arch bars gradually pull the teeth into occlusion and, in turn, the
Fig. 4.— a, impacted transverse fracture of maxilla, b, fracture reduced by intermaxillary traction with rubber; additional downward traction gained by use of a strong rubber band (right angle of mouth) attached to upper dental arch bar and to curved rod fixed to plaster head cast.
ances which restore the teeth to the nor mal and original occlusion. Even though the upper jaw is freely m ovable in most instances, it is not possible to manipulate it into correct position. O n the con trary, one must depend upon traction with rubber bands to secure satisfactory reduction of the fracture and normal occlusion of the teeth. T h e gradual, continuous pull o f rubber bands, when applied in the right direction, invariably will restore a displaced upper jaw to its
upper jaw into proper alinement. I f the m axilla is displaced backward, direct anterior traction becomes necessary in order to effect complete reduction of the fracture. (Fig. 3a.) This can be ac complished by stretching a rubber band from the upper arch bar to a rod at tached to a plaster head cast. Such trac tion with rubber bands will give suffi cient pull in a forward direction to bring the jaw into the desired position. In m any cases of transverse m axillary frac-
788
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
ture, the upper jaw is displaced upward and backward to a marked degree, and very often the loose fragm ent is im pacted in this position. (Fig. 4a.) Under such circumstances, strong downward traction is required to bring the teeth into occlusion. Here, a strong rubber band stretched from the upper arch bar to a curved rod, which passes downward anteriorly to the chin from the head cast, will give the desired downward pull upon the upper jaw . (Fig. 4b.) When the superior m axilla is displaced down ward, its upward elevation can be nicely accomplished by the use of turn buckles. This phase of the reduction of these frac tures will be considered later.
Fig. 5.— Immobilization of pyramidal facial fracture with edentulous upper jaw. Traction wires are attached to a vulcanite splint.
A fter the reduction of the fractured upper jaw and the restoration of normal dental occlusion, some form of immobil ization becomes necessary to maintain the upper jaw in proper position until healing has occurred. For fixation, I have tried m any methods which have been advocated in the literature, and I have come to the conclusion that I can obtain the most satisfactory results by the use o f traction wires inserted through the cheeks as was first described by Federspiel. (Fig. 3b and c.) In the ap
plication of such traction wires, I em ploy two double strands of 26-gage bronze wire. Each strand is attached to the upper arch bar in the bicuspid region, passed directly through the cheek, and is fixed to a plaster head cast above. These traction wires permit a di rect upward pull upon the upper jaw. T h ey offer a form of immobilization which can be maintained for an indefi nite period of time and which leads to a strong bony union of the m axillary frac ture. W hen one employs traction wires which are attached to a fixed post on the head cast, there is a strong probability o f producing in each cheek a linear scar, which m ay become retracted to form a dimple. T h e explanation of such scarring is based upon the fact that a straight line between the upper arch bar and a fixed post on the head cap passes through the skin of the cheek at a very definite point. Since it is impossible for one to deter mine the exact position of this point, when the traction wire is inserted through the cheek, it usually emerges several millimeters away from the de sired point. Consequently, when the wire is made tense, it pushes the soft tissues aside and the subsequent inflam matory reaction cuts through the skin to produce a linear scar. However, by the use of adjustable hooks attached to the head cast, I have been able to overcome this undesirable scarring of the cheeks. (Fig. 3b and c.) I employ two hooks, which slide from side to side upon a curved rod fixed to three metal posts in corporated in the plaster head cap. These hooks also can be made to swing anteriorly or posteriorly as desired. Through this range of movement, the hooks can be adjusted so as to engage the traction wires in any plane in which they emerge from the cheeks. This pre vents any lateral pressure of the traction wires upon the soft tissues and, in turn, any tendency of these wires to cut through the cheeks.
E r ic h — F r a c t u r e s o f U p p e r J a w
Recently, I have found that the effi ciency o f traction wires can be m ate rially increased by attaching a small turnbuckle to each adjustable hook. The purpose of turnbuckles is tw o fo ld : First, should the head cast tip forward a trifle, a simple adjustment of the turnbuckles will readily take up the resultant slack in the traction wires. However, of more
789
or three successive days, the loose seg ment o f bone, including the upper jaw, can be gradually elevated to correct posi tion. (Fig. 3b and c.) In the few cases in which upward traction becomes nec essary, the upward pull produced by turnbuckles can be supplemented by traction with rubber bands. I would like to consider briefly the
Fig. 6.— Transverse maxillary fractures associated with fractures of palate, a, median line fracture of palate, b, multiple fractures of palate reduced by intermaxillary traction with rubber bands, c, fragments immobilized by traction wires attached to lower arch bar.
importance is the value of turnbuckles in pyram idal and transverse facial frac tures in which the m axilla is displaced downward. Here, by giving the turn buckles a few rotary movements on two
use of plaster headcasts, which m any surgeons have discarded for some form of adjustable headgear that can be trans ferred from one patient to another. W ith such appliances, they are able to obtain
790
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
Fig. 7.— a, unilateral fracture of right upper jaw associated with depressed fracture of right malar bone and fracture of right horizontal ramus of mandible, b, cast silver splint immobiliz ing lower jaw fragments and spanning edentulous region of right mandible; fragment of upper jaw forced outward by means of a jackscrew. c, teeth brought into occlusion and fracture of upper jaw completely reduced by intermaxillary traction with rubber bands.
E r ic h — F r a c t u r e s
excellent results. However, in our prac tice at the clinic, it has been m y experi ence that plaster head casts are more satisfactory, since, it appears to me, they are more stable over a long period of time. In the construction of a plaster head cast, I follow, in general, the method described by Iv y and C u rtis: A stockinet is placed over the patient’s head, after which four strips o f felt are applied in such manner as to cover the frontal prominences and parietal regions. These felt pads are retained in position b y ad hesive tape. I f its upper end is left sev eral inches long, the stockinet can be pulled down as a cuff to cover the felt pads. T he next step consists in the appli cation of a plaster bandage, which is adapted closely to the mastoid processes and which is carried down well over the occipital protuberance posteriorly and to the eyebrows in front. Incorporated in the plaster cap is a metal band (1 inch wide) to which three metal posts have been soldered. B y means of set thumb screws, any of the appliances which we em ploy in the treatment of fractured facial bones can be attached securely to one or more of these three posts. T o insure its thorough stability, it is important, I believe, that the head cap fit tightly over the mastoid proc esses. This can be accomplished by pil ing up several thicknesses o f gauze over that portion o f the completed wet plas ter cast which covers the mastoid proc esses. T h en if the gauze is bandaged in place for twenty-four hours while the plaster is drying, the head cast will be come adapted perfectly to the mastoid regions. I have found it desirable to relieve the head cap anteriorly when traction wires are employed because the latter tend to tip the plaster cast down, with the re sult that an undue amount of pressure is applied to the forehead. In order to relieve this portion o f the head cast, I usually apply a strip o f felt one-quarter
of
U
pper
791
Jaw
inch thick to the forehead before the stockinet is applied. After the head cast has been completed, this piece of felt is removed, a space remaining between the cap and the skin of the forehead. By this procedure, any pressure sores or necrosis in the forehead region is obvi ated subsequently to fixation of traction wires in proper position. Fractures o f the facial bones, with complete separation of an edentulous upper jaw at times, offer considerable difficulty in reduction. It is not always possible to reduce such fractures com pletely, but this is usually o f little con sequence provided the upper jaw can be thoroughly stabilized to bring about a good bony union of the fracture line. It has been my experience in such cases that traction wires which are attached to the upper denture or to a vulcanite splint give very satisfactory immobiliza tion for the m axilla and aid in securing the desired bony union. (Fig. 5.) t r a n s v e r s e f r a c t u r e s o f t h e m a x il l a e a s s o c ia t e d w it h o n e o r m o r e f r a c tures
OF T H E P A L A T E
When a transverse fracture of the maxillae is associated with one or more fractures of the palate, it is necessary that the fragments of the palate and alveolar process be brought into correct apposition before the upper teeth are returned to normal occlusion with the lower dental arch by elastic traction. T h e most common type o f palatal frac ture is the one which occurs in the median line. (Fig. 6a.) In cases o f this type, I apply a hooked arch bar to the upper teeth and, subsequently, divide the arch bar at the site of the median line fracture. O n each side, a hook is at tached to each arch bar segment so as to emerge lingually in the interproximal space between the second bicuspid and first molar teeth. A rubber band then stretched between these two hooks will gradually bring the two halves o f the palate and alveolar process into proper
792
T
he
Journal
of th e
A
m e r ic a n
approximation. (Fig. 6a.) O ne can then proceed w ith the reduction of the trans verse m axillary fracture by the use of vertical traction with rubber bands, as has been described. In m ultiple fractures of the palate, associated with a transverse m axillary fracture, there is often but a single tooth present in a fragment. (Fig. 6b.) W hen such a tooth is to be used for stabiliza tion o f the fragm ent, I believe that it is preferable to adapt an orthodontia molar band to the tooth rather than to apply a wire around the neck of the tooth. Such a molar band, when securely attached to the tooth, cannot be displaced and its buccal sheath serves as an excellent at tachment for intermaxillary rubber bands or wires. Where there are several teeth in a fragm ent, it is preferable to employ a portion of an arch bar, wiring it to each tooth in the fragment. Then vertical rubber bands stretched from the upper m olar bands or arch bar segments to a hooked arch bar below will grad ually bring the upper teeth down into normal occlusion with the lower dental arch. Since there is no full upper arch bar to which traction wires can be a t tached, it is necessary that they be ap plied to the lower arch bar. (Fig. 6c.) This procedure firmly fixes the mandible, and, in turn, the fragments o f the upper jaw are immobilized. Reduction o f a transverse m axillary fracture associated with one or more fractures o f the palate is particularly difficult if the fracture is associated also w ith fractures of the mandible. T he perplexing problem in the management o f such fractures arises in the fact that there is no fixed point from which one can begin to reduce the fractures. Con sequently, it becomes necessary to create a fixed point. Usually, I em ploy a cast silver splint to immobilize the fragments of the lower jaw and then, by inter m axillary traction w ith rubber bands, force the upper teeth into occlusion with
D
ental
A
s s o c ia t io n
the teeth o f the lower dental arch. (Fig. 2.) In the construction o f such a cast silver splint, it is necessary, of course, to take impressions o f the teeth in each fragment and prepare plaster models from these impressions. T h e plaster models are then mounted upon an artic ulator in normal occlusion, after which the cast silver splint can be made. A l though it is not always possible under these circumstances to establish the exact original plane of occlusion, the ultimate result invariably is satisfactory from both a functional and an esthetic standpoint. U N ILA T E R A L F R A C T U R E S O F T H E U P PE R JA W
Usually, a unilateral fracture of the upper jaw is the result of a blow directed from the side and, consequently, the loose fragm ent of bone is displaced downward and inward. (Fig. 7a.) M ore over, such a fracture is commonly asso ciated with a depressed fracture of the malar bone on the same side, and not infrequently with a fracture of the m an dible and a loss o f several lower teeth. In m any instances, it is possible to manipulate the loose fragment of the upper jaw into proper position and im mobilize it merely by wiring the teeth in occlusion. H owever, in some cases, forceful reduction of the m axillary frac ture is entirely unsatisfactory and special appliances for reduction and immobiliza tion become essential. T o reduce a frac ture o f this type, I usually employ ortho dontic m olar bands, attaching one to the upper first m olar tooth on each side (Fig. 7b). A jackscrew inserted between these two m olar bands will force the loose fragment o f the upper jaw out ward. Although such an appliance will push this fragment laterally, it will not correct the downward displacement. W hen the patient attempts to close his mouth, the teeth of this fragment come in contact with the teeth of the lower jaw, but an open bite is left on the op
E r ic h — F r a c t u r e s
posite side of the mouth. T o overcome this and force the loose fragm ent of bone upward into position, it is necessary to apply an arch bar to the unfractured portion of the upper jaw and a full arch bar to the teeth of the lower jaw. Interm axillary traction with rubber bands between these two arch bars will gradually close the open bite on the one side and, in turn, will force the loose fragm ent of bone on the opposite side upward into correct position. (Fig. 7c.) If the teeth of the lower jaw on the in volved side are lost at the time of the injury, it is necessary to em ploy a cast silver splint, which is cemented to the teeth on the opposite side o f the m an dible. This splint is constructed with a saddle to fit over the alveolar ridge on the edentulous injured side of the lower jaw. T h e saddle serves as an occlusal plane on which the teeth of the right upper fragm ent can rest, when the latter is forced upward into position. I f there is but one remaining m olar tooth in the mandible on the involved side, as is shown in Figure 7 a and b, the cast silver splint is so made as to span the edentu lous region and possesses a lingual rest for the above-mentioned m olar tooth. Such a splint can also be employed in cases in which the lower jaw is frac tured as is demonstrated in Figure 7b and c. Here, the cast silver splint not only forms the desired occlusal plane for the fractured upper jaw , but also im mobilizes the fragments of the mandible.
of
U
pper
Ja w
793
SIM PLE FR A C TU R E OF T H E U P P E R A L V E O L A R PRO CESS
Simple fracture of the upper alveolar process requires no special consideration in this paper. I f the periosteum o f the loose fragm ent o f the upper alveolar process is not completely detached, the fragment should be retained and im mobilized by a splint or intermaxillary wires. However, if the roots of the teeth in such a fragm ent are exposed in the line of fracture, it is, I believe, prefer able to remove these teeth and even the fragment of bone if necessary. SU M M A R Y
Fractures of the upper jaw have been classified or arranged into four groups in accordance with their treatm ent: 1. Fractures which cause a complete separation of the upper jaw from the rest o f the skull. 2. Transverse fractures of the m ax illae associated with one or more frac tures o f the palate. 3. U nilateral fractures of the upper jaw. 4. Simple fractures of the upper al veolar process. B IB LIO G R A PH Y
M. M .: Maxillo-Facial In Wisconsin M. ]., 33:561-568, August
1. F e d e r s p ie l,
juries. 19 34 -
2. Ivv, R. H., and C u r t i s , L a w r e n c e : Fractures of Jaws. Philadelphia: Lea & Febiger, 1931.
tion of each patient. T h e dental profes sion has a great responsibility, and we must meet it. It is our obligation to be fair and honest with the public. I am afraid that we are prone to forget some of these obligations. T h e “ Doctor” be
of
U
pper
Jaw
783
fore our names means a great deal more to the public than we at times realize. So let us be careful to uphold the title that we bear, and make the public feel that it can put its trust in us. Medical Arts Building.
TREATMENT OF FRACTURES OF THE UPPER JA W By
John
B.
E r ic h ,
D .D .S., M .D ., Rochester, Minn.
R O M the standpoint of therapy, no injuries affecting the bones of the face offer more intricate problems than do fractures of the upper jaw. The treatment of any fractures of the jaw has two objectives: first, reduction of the fracture in a manner not only to replace the fragments in their original position, but also to restore the teeth to normal occlusion; and, second, immobilization that will lead to a strong bony union of the fragments. In a case o f fracture of the maxilla, the selection of the method or methods best adapted to attain both of these objectives requires a great deal of preoperative planning and frequently the preparation of rather elaborate ap pliances. Extremely helpful in determin ing the treatment most suitable in an individual case is a comprehensive knowledge of present-day operative pro cedures. Although a review o f these procedures as described in the literature is both instructive and interesting, it also is likely to be somewhat confusing. One finds that different opinions are enter tained in regard to the treatment of vari ous types of fractures of the upper jaw,
F
From the Section on Laryngology, Oral and Plastic Surgery, The Mayo Clinic, Read before the Section on Oral Surgery, Exodontia and Anesthesia at the Eighty-Third Annual Meeting of the American Dental As sociation, Houston, Texas, October 30, 1941. Jour. A .D .A., V ol. 29, M ay 1942
opinions which are indeed often com pletely contradictory. T h e explanation of this situation rests in part on personal prejudice and par tiality that prevent a proper estimation of the merits of various procedures. Then too, some methods described in detail in the literature deal not with the general, but with a particular, case. Moreover, every surgeon, through his own natural qualities, has instinctive methods of operating. A technic which is most effi cient when applied by one operator m ay be rather unsatisfactory in the hands of another. Consequently, in considering fractures of the upper jaw, one cannot insist that his methods are superior to all others, but can merely present those procedures which in his experience have given the most effective results. T h e treatment o f any fractured jaw is successful only when the continuity of the bone has been established and the normal masticatory mechanism has been restored. T h e fragments of a fractured jaw m ay heal firmly by bony union, but the end-result is a failure if the original occlusion of the teeth has not been re established, to insure normal mastication. Nearly every fracture of a jaw in which there is the least displacement of the fragments causes some disturbance of occlusion, and unless the teeth can be brought into normal relationship, the
784
T
he
Journal
of th e
A
m e r ic a n
fragments will not be restored to their original position. Nothing serves as a better guide to the proper position of the fragments than does the occlusion of the teeth. Frequently, in cases o f frac ture o f the jaws, it is almost impossible to. determine by visual inspection o f the mouth w hat relationship actually existed between the upper and lower teeth be fore the fracture occurred. This m ay be the result o f the loss o f m any teeth in each dental arch or it m ay be due to primary malocclusion of the teeth. C on sequently, the preparation o f plaster study models of the dental arches will aid materially in determination of the original occlusion. In general, then, the treatment of fractures of the upper jaw should be deferred not only until maxillodental
D
ental
A
s s o c ia t io n
vention of an abscess and possible osteo myelitis. As a matter of convenience in discuss ing the therapeutic management o f frac tures of the upper jaw, I have found it advantageous to classify such fractures in four groups : (1) fractures which pro duce a complete separation of the upper jaw from the rest of the skull, (2) trans verse fractures o f the m axilla associated with one or more fractures of the palate, (3) unilateral fractures o f the upper jaw and (4) simple fractures of the upper alveolar process. (Fig. 1.) fractu res
c a u s in g
a
com plete
separa
t io n o f t h e u p p e r j a w f r o m t h e rest of th e sk u l l
It is advisable to consider three forms of fractures which produce complete
Fig. 1.— Fractures which produce complete separation of upper jaw from remainder of the skull, a, transverse maxillary fracture, b, pyramidal facial fracture, c, transverse facial fracture.
roentgenograms can be secured, but also until plaster study models can be pre pared. O n ly with such accessory diag nostic agencies can one accurately deter mine the best method o f reducing the fracture and of immobilizing the frag ments. Prior to the actual reduction of the fracture, débris and loose pieces of bone, which unquestionably would form sequestra, should be removed. Further more, I wish to stress the importance of extracting every tooth the root of which is exposed in a line of fracture unless the tooth is absolutely necessary for the fix ation of a bony fragment. In m y ex perience, the removal o f such teeth is an extremely important step in the pre
separation of the maxillae from the rest of the skull. As illustrated in Figure 1, the first and most common type is the horizontal or transverse fracture o f the upper jaw in which the greater portion of the m axilla is detached as a free seg ment. T h e second type, not infrequently encountered, is the pyram idal facial fracture (so-called because it assumes the form o f a pyramid) which extends up ward through each antrum to the eth moid region and base of the nose. In this form, the loose fragment is composed of the entire m axillae and the nasal bones. Pyramidal facial fractures are often associated with a depressed or com minuted fracture of one malar bone. O f
E r ic h — F r a c t u r e s o f U p p e r J a w
rare occurrence is the third type, which may be described as a transverse facial fracture passing through the base of the nasal and ethmoid regions and across the orbits to the zygomatic arches. This fracture is of such character that the upper jaw, m alar and nasal bones con stitute one complete displaced structure. As would be expected, the last type of fracture is extremely uncommon because it almost invariably is present in con junction with depressed fractures of both malar bones, and, under such circum stances, the facial injury actually is con verted into a combination of a pyramidal facial and a transverse facial fracture. One should not overlook the fact that
7^5
ture, there is a tendency for the upper jaw to be forced upward and backward with a resultant open-bite type of de formity. Pyramidal facial and transverse facial fractures, on the other hand, are likely to cause a downward displacement o f the upper jaw with varying degrees o f malposition between the upper dental arch and the lower teeth. In such in stances, roentgenograms frequently re veal a space several millimeters in width between the upper border of the 'nasal bones and the glabella portion of the frontal bone, and there is frequently an associated fracture o f the cribriform plate of the ethmoid bone. It is not un common, in cases of fractures of the
Fig. 2.— a, multiple fractures of facial bones including transverse maxillary fracture, pyra midal facial fracture and transverse facial fracture, b, fractures reduced and immobilized.
two or all three of these fractures m ay exist together in the same patient. (Fig. 2.) M oreover, fractures o f the malar, nasal and ethmoid bones are frequently encountered in connection with severe fracture of the upper jaws. A lthough the three fractures which have been described possess definite an atomic differences, the objective intra oral findings are often indistinguishable. Clinically, the upper jaw is loose and movable and more or less displaced so that the teeth do not occlude properly. However, in a transverse m axillary frac-
ethmoid bone, to find that cerebrospinal fluid drains from the nose for several days following the injury. Since cerebro spinal rhinorrhea is a sign of serious bony trauma in the ethmoid region and re quires specific therapeutic management, its recognition in all cases of severe in jury to the upper ja w or to the nose cannot be stressed too strongly. In spite of the fact that the thera peutic management of the three types o f fractures under consideration is essen tially the same, their early clinical recog nition through roentgenographic studies
786
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
is distinctly advantageous. By determin ing which one or combination of these fractures exists in each individual case, one can predict with a fair degree of accuracy the difficulty which will be encountered in the reduction of the frac ture. In cases of pyramidal or a trans verse facial fracture, reduction is usually a much more difficult task than in cases of a simple transverse m axillary fracture.
moid bone, a complication that m ay lead to a fatal meningitis. In treating fractures of the upper jaw associated with fracture o f the cribriform plate of the ethmoid bone, any injury o f the overlying soft tissues o f the face should, I believe, be taken care of as soon after the injury as is feasible. H ow ever, it is extremely important not to treat the fractured facial bones for from
Fig. 3.— Reduction and immobilization of pyramidal facial fracture, a, traction with rubber bands bringing teeth into normal occlusion, b, turnbuckles attached to traction wires and hooks on head cast elevating loose fragment of bone; adjustable hooks on head cast preventing un necessary scarring of cheeks, c, pyramidal facial fracture immobilized by traction wires through cheeks.
Furthermore, the preoperative diagnosis of the type of fracture present is of value in ascertaining the gravity of the injury, since fractures of the second and third type are frequently associated with frac ture of the cribriform plate of the eth-
ten to fourteen days after the injury because any manipulation of these bones m ay disturb the fracture o f the ethmoid bone and induce meningitis. A fter this length of time, the fracture in the eth moid region has become walled off to a
E r ic h — F r a c t u r e s
certain extent by fibrous tissue, and it is then safe to proceed with whatever measures are necessary to reduce and im mobilize the fractured bones of the face. During the interval of from ten to four teen days, it is well to give the patient one of the sulfonamide preparations as an aid in the prevention of meningitis. As applies to all fractures, the treat ment of injuries of the facial bone which are associated with a complete separation o f the upper jaw from the rest o f the skull consists first in reduction and later in immobilization of the parts involved. T h e reduction of these fractures, in gen eral, is based upon mechanical appli-
of
U
pper
Jaw
787
proper position, whereas the ultimate result would be more or less o f a failure if one attempted m anually to replace the fractured m axillae in accurate alinement. T h e reduction by elastic traction of the three types o f m axillary fracture under consideration requires, first, the application to the upper dental arch of a hooked arch bar, which is wired securely to each upper tooth. (Fig. 3.) Next, a similar arch bar is wired to the teeth of the lower jaw . T h en rubber bands stretched between the hooks of the up per and lower arch bars gradually pull the teeth into occlusion and, in turn, the
Fig. 4.— a, impacted transverse fracture of maxilla, b, fracture reduced by intermaxillary traction with rubber; additional downward traction gained by use of a strong rubber band (right angle of mouth) attached to upper dental arch bar and to curved rod fixed to plaster head cast.
ances which restore the teeth to the nor mal and original occlusion. Even though the upper jaw is freely m ovable in most instances, it is not possible to manipulate it into correct position. O n the con trary, one must depend upon traction with rubber bands to secure satisfactory reduction of the fracture and normal occlusion of the teeth. T h e gradual, continuous pull o f rubber bands, when applied in the right direction, invariably will restore a displaced upper jaw to its
upper jaw into proper alinement. I f the m axilla is displaced backward, direct anterior traction becomes necessary in order to effect complete reduction of the fracture. (Fig. 3a.) This can be ac complished by stretching a rubber band from the upper arch bar to a rod at tached to a plaster head cast. Such trac tion with rubber bands will give suffi cient pull in a forward direction to bring the jaw into the desired position. In m any cases of transverse m axillary frac-
788
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
ture, the upper jaw is displaced upward and backward to a marked degree, and very often the loose fragm ent is im pacted in this position. (Fig. 4a.) Under such circumstances, strong downward traction is required to bring the teeth into occlusion. Here, a strong rubber band stretched from the upper arch bar to a curved rod, which passes downward anteriorly to the chin from the head cast, will give the desired downward pull upon the upper jaw . (Fig. 4b.) When the superior m axilla is displaced down ward, its upward elevation can be nicely accomplished by the use of turn buckles. This phase of the reduction of these frac tures will be considered later.
Fig. 5.— Immobilization of pyramidal facial fracture with edentulous upper jaw. Traction wires are attached to a vulcanite splint.
A fter the reduction of the fractured upper jaw and the restoration of normal dental occlusion, some form of immobil ization becomes necessary to maintain the upper jaw in proper position until healing has occurred. For fixation, I have tried m any methods which have been advocated in the literature, and I have come to the conclusion that I can obtain the most satisfactory results by the use o f traction wires inserted through the cheeks as was first described by Federspiel. (Fig. 3b and c.) In the ap
plication of such traction wires, I em ploy two double strands of 26-gage bronze wire. Each strand is attached to the upper arch bar in the bicuspid region, passed directly through the cheek, and is fixed to a plaster head cast above. These traction wires permit a di rect upward pull upon the upper jaw. T h ey offer a form of immobilization which can be maintained for an indefi nite period of time and which leads to a strong bony union of the m axillary frac ture. W hen one employs traction wires which are attached to a fixed post on the head cast, there is a strong probability o f producing in each cheek a linear scar, which m ay become retracted to form a dimple. T h e explanation of such scarring is based upon the fact that a straight line between the upper arch bar and a fixed post on the head cap passes through the skin of the cheek at a very definite point. Since it is impossible for one to deter mine the exact position of this point, when the traction wire is inserted through the cheek, it usually emerges several millimeters away from the de sired point. Consequently, when the wire is made tense, it pushes the soft tissues aside and the subsequent inflam matory reaction cuts through the skin to produce a linear scar. However, by the use of adjustable hooks attached to the head cast, I have been able to overcome this undesirable scarring of the cheeks. (Fig. 3b and c.) I employ two hooks, which slide from side to side upon a curved rod fixed to three metal posts in corporated in the plaster head cap. These hooks also can be made to swing anteriorly or posteriorly as desired. Through this range of movement, the hooks can be adjusted so as to engage the traction wires in any plane in which they emerge from the cheeks. This pre vents any lateral pressure of the traction wires upon the soft tissues and, in turn, any tendency of these wires to cut through the cheeks.
E r ic h — F r a c t u r e s o f U p p e r J a w
Recently, I have found that the effi ciency o f traction wires can be m ate rially increased by attaching a small turnbuckle to each adjustable hook. The purpose of turnbuckles is tw o fo ld : First, should the head cast tip forward a trifle, a simple adjustment of the turnbuckles will readily take up the resultant slack in the traction wires. However, of more
789
or three successive days, the loose seg ment o f bone, including the upper jaw, can be gradually elevated to correct posi tion. (Fig. 3b and c.) In the few cases in which upward traction becomes nec essary, the upward pull produced by turnbuckles can be supplemented by traction with rubber bands. I would like to consider briefly the
Fig. 6.— Transverse maxillary fractures associated with fractures of palate, a, median line fracture of palate, b, multiple fractures of palate reduced by intermaxillary traction with rubber bands, c, fragments immobilized by traction wires attached to lower arch bar.
importance is the value of turnbuckles in pyram idal and transverse facial frac tures in which the m axilla is displaced downward. Here, by giving the turn buckles a few rotary movements on two
use of plaster headcasts, which m any surgeons have discarded for some form of adjustable headgear that can be trans ferred from one patient to another. W ith such appliances, they are able to obtain
790
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
Fig. 7.— a, unilateral fracture of right upper jaw associated with depressed fracture of right malar bone and fracture of right horizontal ramus of mandible, b, cast silver splint immobiliz ing lower jaw fragments and spanning edentulous region of right mandible; fragment of upper jaw forced outward by means of a jackscrew. c, teeth brought into occlusion and fracture of upper jaw completely reduced by intermaxillary traction with rubber bands.
E r ic h — F r a c t u r e s
excellent results. However, in our prac tice at the clinic, it has been m y experi ence that plaster head casts are more satisfactory, since, it appears to me, they are more stable over a long period of time. In the construction of a plaster head cast, I follow, in general, the method described by Iv y and C u rtis: A stockinet is placed over the patient’s head, after which four strips o f felt are applied in such manner as to cover the frontal prominences and parietal regions. These felt pads are retained in position b y ad hesive tape. I f its upper end is left sev eral inches long, the stockinet can be pulled down as a cuff to cover the felt pads. T he next step consists in the appli cation of a plaster bandage, which is adapted closely to the mastoid processes and which is carried down well over the occipital protuberance posteriorly and to the eyebrows in front. Incorporated in the plaster cap is a metal band (1 inch wide) to which three metal posts have been soldered. B y means of set thumb screws, any of the appliances which we em ploy in the treatment of fractured facial bones can be attached securely to one or more of these three posts. T o insure its thorough stability, it is important, I believe, that the head cap fit tightly over the mastoid proc esses. This can be accomplished by pil ing up several thicknesses o f gauze over that portion o f the completed wet plas ter cast which covers the mastoid proc esses. T h en if the gauze is bandaged in place for twenty-four hours while the plaster is drying, the head cast will be come adapted perfectly to the mastoid regions. I have found it desirable to relieve the head cap anteriorly when traction wires are employed because the latter tend to tip the plaster cast down, with the re sult that an undue amount of pressure is applied to the forehead. In order to relieve this portion o f the head cast, I usually apply a strip o f felt one-quarter
of
U
pper
791
Jaw
inch thick to the forehead before the stockinet is applied. After the head cast has been completed, this piece of felt is removed, a space remaining between the cap and the skin of the forehead. By this procedure, any pressure sores or necrosis in the forehead region is obvi ated subsequently to fixation of traction wires in proper position. Fractures o f the facial bones, with complete separation of an edentulous upper jaw at times, offer considerable difficulty in reduction. It is not always possible to reduce such fractures com pletely, but this is usually o f little con sequence provided the upper jaw can be thoroughly stabilized to bring about a good bony union of the fracture line. It has been my experience in such cases that traction wires which are attached to the upper denture or to a vulcanite splint give very satisfactory immobiliza tion for the m axilla and aid in securing the desired bony union. (Fig. 5.) t r a n s v e r s e f r a c t u r e s o f t h e m a x il l a e a s s o c ia t e d w it h o n e o r m o r e f r a c tures
OF T H E P A L A T E
When a transverse fracture of the maxillae is associated with one or more fractures of the palate, it is necessary that the fragments of the palate and alveolar process be brought into correct apposition before the upper teeth are returned to normal occlusion with the lower dental arch by elastic traction. T h e most common type o f palatal frac ture is the one which occurs in the median line. (Fig. 6a.) In cases o f this type, I apply a hooked arch bar to the upper teeth and, subsequently, divide the arch bar at the site of the median line fracture. O n each side, a hook is at tached to each arch bar segment so as to emerge lingually in the interproximal space between the second bicuspid and first molar teeth. A rubber band then stretched between these two hooks will gradually bring the two halves o f the palate and alveolar process into proper
792
T
he
Journal
of th e
A
m e r ic a n
approximation. (Fig. 6a.) O ne can then proceed w ith the reduction of the trans verse m axillary fracture by the use of vertical traction with rubber bands, as has been described. In m ultiple fractures of the palate, associated with a transverse m axillary fracture, there is often but a single tooth present in a fragment. (Fig. 6b.) W hen such a tooth is to be used for stabiliza tion o f the fragm ent, I believe that it is preferable to adapt an orthodontia molar band to the tooth rather than to apply a wire around the neck of the tooth. Such a molar band, when securely attached to the tooth, cannot be displaced and its buccal sheath serves as an excellent at tachment for intermaxillary rubber bands or wires. Where there are several teeth in a fragm ent, it is preferable to employ a portion of an arch bar, wiring it to each tooth in the fragment. Then vertical rubber bands stretched from the upper m olar bands or arch bar segments to a hooked arch bar below will grad ually bring the upper teeth down into normal occlusion with the lower dental arch. Since there is no full upper arch bar to which traction wires can be a t tached, it is necessary that they be ap plied to the lower arch bar. (Fig. 6c.) This procedure firmly fixes the mandible, and, in turn, the fragments o f the upper jaw are immobilized. Reduction o f a transverse m axillary fracture associated with one or more fractures o f the palate is particularly difficult if the fracture is associated also w ith fractures of the mandible. T he perplexing problem in the management o f such fractures arises in the fact that there is no fixed point from which one can begin to reduce the fractures. Con sequently, it becomes necessary to create a fixed point. Usually, I em ploy a cast silver splint to immobilize the fragments of the lower jaw and then, by inter m axillary traction w ith rubber bands, force the upper teeth into occlusion with
D
ental
A
s s o c ia t io n
the teeth o f the lower dental arch. (Fig. 2.) In the construction o f such a cast silver splint, it is necessary, of course, to take impressions o f the teeth in each fragment and prepare plaster models from these impressions. T h e plaster models are then mounted upon an artic ulator in normal occlusion, after which the cast silver splint can be made. A l though it is not always possible under these circumstances to establish the exact original plane of occlusion, the ultimate result invariably is satisfactory from both a functional and an esthetic standpoint. U N ILA T E R A L F R A C T U R E S O F T H E U P PE R JA W
Usually, a unilateral fracture of the upper jaw is the result of a blow directed from the side and, consequently, the loose fragm ent of bone is displaced downward and inward. (Fig. 7a.) M ore over, such a fracture is commonly asso ciated with a depressed fracture of the malar bone on the same side, and not infrequently with a fracture of the m an dible and a loss o f several lower teeth. In m any instances, it is possible to manipulate the loose fragment of the upper jaw into proper position and im mobilize it merely by wiring the teeth in occlusion. H owever, in some cases, forceful reduction of the m axillary frac ture is entirely unsatisfactory and special appliances for reduction and immobiliza tion become essential. T o reduce a frac ture o f this type, I usually employ ortho dontic m olar bands, attaching one to the upper first m olar tooth on each side (Fig. 7b). A jackscrew inserted between these two m olar bands will force the loose fragment o f the upper jaw out ward. Although such an appliance will push this fragment laterally, it will not correct the downward displacement. W hen the patient attempts to close his mouth, the teeth of this fragment come in contact with the teeth of the lower jaw, but an open bite is left on the op
E r ic h — F r a c t u r e s
posite side of the mouth. T o overcome this and force the loose fragm ent of bone upward into position, it is necessary to apply an arch bar to the unfractured portion of the upper jaw and a full arch bar to the teeth of the lower jaw. Interm axillary traction with rubber bands between these two arch bars will gradually close the open bite on the one side and, in turn, will force the loose fragm ent of bone on the opposite side upward into correct position. (Fig. 7c.) If the teeth of the lower jaw on the in volved side are lost at the time of the injury, it is necessary to em ploy a cast silver splint, which is cemented to the teeth on the opposite side o f the m an dible. This splint is constructed with a saddle to fit over the alveolar ridge on the edentulous injured side of the lower jaw. T h e saddle serves as an occlusal plane on which the teeth of the right upper fragm ent can rest, when the latter is forced upward into position. I f there is but one remaining m olar tooth in the mandible on the involved side, as is shown in Figure 7 a and b, the cast silver splint is so made as to span the edentu lous region and possesses a lingual rest for the above-mentioned m olar tooth. Such a splint can also be employed in cases in which the lower jaw is frac tured as is demonstrated in Figure 7b and c. Here, the cast silver splint not only forms the desired occlusal plane for the fractured upper jaw , but also im mobilizes the fragments of the mandible.
of
U
pper
Ja w
793
SIM PLE FR A C TU R E OF T H E U P P E R A L V E O L A R PRO CESS
Simple fracture of the upper alveolar process requires no special consideration in this paper. I f the periosteum o f the loose fragm ent o f the upper alveolar process is not completely detached, the fragment should be retained and im mobilized by a splint or intermaxillary wires. However, if the roots of the teeth in such a fragm ent are exposed in the line of fracture, it is, I believe, prefer able to remove these teeth and even the fragment of bone if necessary. SU M M A R Y
Fractures of the upper jaw have been classified or arranged into four groups in accordance with their treatm ent: 1. Fractures which cause a complete separation of the upper jaw from the rest o f the skull. 2. Transverse fractures of the m ax illae associated with one or more frac tures o f the palate. 3. U nilateral fractures of the upper jaw. 4. Simple fractures of the upper al veolar process. B IB LIO G R A PH Y
M. M .: Maxillo-Facial In Wisconsin M. ]., 33:561-568, August
1. F e d e r s p ie l,
juries. 19 34 -
2. Ivv, R. H., and C u r t i s , L a w r e n c e : Fractures of Jaws. Philadelphia: Lea & Febiger, 1931.