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Treatment of multiple facial fractures
Operative TREATMENT
Oral
OF MULTIPLE
Surgery FACIAL
FRACTURES
Report of a Case DAS E. BRANNIN, B.S., D.D.S., M.S.D.,” WILKINSON, D.D.S., M.S.D.,“”
TULSA, OKLA., ASD CHARLES MINNEAPOLIS, MIXY.
1~.
T
HERE are many effective means of treating fractures of the facial bones. However, before one may attempt the care of such conditions he must possess a full understanding of the relationship and function of these structures. When either the maxillae or mandible is involved, a comprehension of jaw function and dental occlusion is an absolute necessity. Thornal states that “injuries of the jaws require highly specialized technical treatment which is directed toward the establishment of normal function of the jaws and teeth, and the prevention of infection and facial disfigurement.” Blair and Ivy2 state that there are two principles which govern the treakment of all fractures: “(1) reduction of the fragments to correct position ; (2) fixation in that position until union occurs.” The simplest method by which these two conditio’ns are met is usually the best. Elaborate and cumbersome external fixation devices are to be avoided if possible. A case report is submitted in which the authors believe that these conditions were fulfilled. Case Report Mr. N. N., a 70-year-old white man, presented at the University Hospital on referral his physician March 23, 1951. He complained of difficulty in eating and speaking. History.-On March 21, 1951, the patient was struck about the head by a horse and rendered unconscious for approximately thirty minutes. He was able to walk as soon as he regained consciousness but experienced pain and difficulty in eating and speaking. The next morning he consulted his physician who told the patient that his lower jaw was fractured. The patient was then referred to the University Hospital for treatment. There was no history of any previous serious illness or operations. A thorough review of past medical history was noncontributory. Examination.-The patient was a 70-year-old well-developed white man who was somewhat disoriented but cooperative. He appeared to have suffered severe trauma to the face. Externally, there was diffuse and intense ecchymoses in the periorbital areas. Further marked ecehymoses were observed in the left cheek, right cheek, neck, and anterior chest (Fig. 1). There was a superficial abrasion of the right ear and cheek. A .from
From The Department of Oral Surgery, Sch~~olIIf Dentistry. 1:niversity of Minnesota. *Clinical Fellow in Oral Surgery. **Clinical Instructor in Oral Surgery.
I+‘ifi’. l.--Preuyel,ati\.,,
Vit,\\ of’ ix+tient t:Vu clays after
ailnlissiun
tu tht: Il~x+i,it:tl.
Examination of the tretll rrvraletl the ~~~iif~~lihd:~r left first l~~molar alltl cuspitl to lw The mantlilmlar right. first premolar and third molar were present as residual quite mobile. Tn the maxillary arch, the maxillary roots. No other teeth were pr(‘sent in the mandible. left central incisor, lateral incisor, cuspitl, lirst molar, and sec*ond molar were present. Also present were the maxillary right central incisor, lateral incisor, cuspi(l, first premolar, These teeth were all to varying degrees loose first molar, second molar, and third molar. as the result of advanced periodontoclasia. Consultations from the Internal hlr(licinc~ and the Neurology services revealed no The general physical condition of the patient was good. evidence of further complications. Roentgenographic Data.-- AU occlusal view of the mandil,ular nymphpsis revealell two overriding fragmentti (Fig. 2). 9 \Vatcsrx’ Gttu3 vic\v of thr skull revraled a fracture of the right infraorllital ridge and separatiull of t.11~ frollto~.?-glllrlatic suture (Fig. 3). A posteroanterior radiograph of the skull further demonstrated separation of the nasofrontal sutures, vertical displacement of the mandibular fragments, and a frarture of the right
TREATMENT
OF XULTIPLE
core:ooid process. The distal fragment of later *al jaw radiographs gave 70 further strat ;ed no displacement of the zygomatic ture line extending superiorly from the left Laboratory and
hemoglobin,
Data.-Blood 13.9 Gm.
Fig. 2.--<)cclusal fract wed mandible. Fig. 3.-Waters’ ridge and separation
view
A
1263
FRACTURES
Oblique the coronoid process was not visible. information. A submentovertical view demonarches. Periapical radiographs revealed a fracfirst molar area.
studies revealed: erythroeytes, differential leukocyte count
roentgenogram
sinus view of the right
FACIAL
Fig.
2.
Fig.
3.
demonstrating
radiograph which reveals frontozygomatic suture.
3,680,000, leukocyte gave the following
displacement a fracture
of of the
fragments right
9, 4,350, result:
of
the
infr ‘aorbital
1264
Fig. Fig. frag :ments
Fig.
4.
Fig.
5.
mandible showing the displaced fra 4.- -l!h :posure of the fractur~~rl of the reducer1 fracture with stainless steel 5.- -DE monstration in PIe ce.
s. holding
the
TREAThtENT
OF ,\ITJLTII’LE
FACIAT,
1265
FRACTURES
neutrophiles,
63, lymphocytes, 29, monocytes, 6, eosinophiles, I, and basophiles, 1. The hem atocrit was 38. Bleeding and clotting times were four minutes each. 1.617, reaction, A, albumin, 0, sug ‘ar 0, Urine studies revealed: specifc gravit,v, eryt hrocytes, 0, and casts 6. Fig. 6.
Fig. 7. Fig. B.--Skin closure of the submandibular incision. Fig. ‘I.-Stainless steel wire passed through a hole in the left infraorbital
ridge.
Treatment From the time of admission the patient had received 100,000 units of aqueous penicilli n every four hours. First Operation.-On March 26, 1951, under Monocaine-epinephrine local anest he&a, mandibular teeth and residual roots were removed. The patient with tstood the remaining the procedure well.
F’ip. fracture
Fig.
8.-Postogerativi~ o~~~lus~l view held in position by two stainless
Fig. 9.--Posteroanterior attached to the maxillary
arch
view bar.
9
roentgenogram dtvnonstmting steel n-ires. roentgenoprwm demonstrating the
the reduced internal
mandibul:rr
transfacial
wires
The anterior submandiI,ulx~, right I e~nporal, and left, infraorbital areas were prepared by first scrubbing t,hern with tincture of green soap followed by tincture of Zephiran An incision was made 1 cm. below the mandible and Chloride. The head was draped. parallel to its lower horder, extending from the left lateral inrisor area to the right
second premolar area. By means of sharp and blunt dissection, the fragments were exposed (Fig. 4). A careful debridement of the area was accomplished. Two through-and-through burr holes, one above the other, were made in each fragment. The fragments were well approximated and retained in place by two stainless steel Z-gauge wires inserted through these holes and crossing each other (Fig. 5). The tissues were approximated with 000 catgut sutures subcutaneously and 0000 silk sutures superficially (Fig. 6). An incision was in the then made 2 cm. posterior to the right eye, extending for 2 cm. superoinferiorlp area of the zygornatie process of the frontal bone. The underlying bone was exposed and a through-and-through burr hole was made in thr bone with a Xo. 3 round burr. Hy stainless steel n-vir
E’ig.
lU.--\-ie\v
of tl:r l,aticnt
three
months
postoyrratively.
infraorbital ridge exposed. A “i-gauge stainless steei wire was introduced (k’ig. ‘i), in the same manner as previously described, to the mucobuccal fornix in the region of the left maxillary first molar. An arch bar was fashioned and secured to the remaining maxillary teeth after the right maxillary first and second premolar residual roots were removed. The stainless steel wires, which at this time were extending int,o the mouth, were secured to the arch wire, and after the maxillary fracture was thus reduced they retained it in correct position. The intraoral wound of the compounded fracture was closed with 000 silk sutures. A pressure bandage consisting of fluffed gauze squares, held firmly in place with two ACE bandages, was then applied to the submandibular and right temporal areas. This bandage also served as a chin support. A light bandage was placed over the left eye. An obtundent eye ointment had earlier been placed under the lid and The patient tolerated the procedure well and was the eye covered with an eye pad. awakening when taken from the operating room.
the immediate Postoperative Course.- ~~The patient 1%as marl13 c:o~~~forta)Jle Ituriug postoperative period wit,h codeine phosphate? I gr. every four hours, as needed. His right eye was swollen and shut the first and scco1~~1lmstoperatirr days but he was able to read on the third postoperative day. The sutures were removed 0x1 the third day and the pressure bandages dispensed with. Postoperative radiographs demonstrated the fragments to be well positioned (Figs. S and 0). The patient was placed on a soft, light protein diet supplemented bp vitamills. The Urology 1)epartment was Postoperatively the patient was unable to void. collsllltrcl and it wa> fount1 tllat he had a hy-pcrtrophied prostate gland n-hich was rr~mov~l Iry t ransurethral resection t hrpe weeks after tlrrl oral surgical procedure:* were carried out. HV was sent home to return May 17, 1951. for remora1 of the wires supporting the maxillae.
Second Operation.-On &lay 18, 1931, the patient was agail taken to the operating room. being premeditated with atropintl sulfate I/lao gr., and morphinrh sulfate, I,$ gr. The right temporal area was infiltrated with procaine, 1 per cent, and epinephrincl, 1:X,000. An extraoral block of the maxillary and mandibular divisions of the right trigeminal nerve was then carried out. The approach was made through the mantlibnlar notch. Thts The wire was wire in this area was exposed by following the previous line of incision. The wound was closed as in the detached from the bone and drawn into the: mouth. previous operation. After local infiltration and an infraorbital nerve l~loclr, a similar procedure was tlonc on the left infraorbital arc’a. Postoperative Course.--The patient was ambnlatoq within six hours after t,he procedure and comfortable throughout the immediate postoperative period. The sutures were removed forty-eight hours postoperatively and the patient sent home the third day. (Xnical and radiographic examinations He returned July 24, 1951, for a final checkup. demonstrated a firnl union of the previously fractured bones. He xvas referred to his teeth ant1 the construrtion of local dentist for extraction of the remaining maxillar) artificial denture,< (Fig. ln1.
Comment 13~ the open reduction of the mandibular fracture and by internal fisation of the upper face fractures, the patient was spared cumhcrsome external iIdjWtmellts anal careful surveillance of apparatus for fixation. Postopcratire Except for the derelopmrnt of urethral ohthe patient were unnecessary. struction postoperatively the patient could ha,vr resumed his normal dut,ies with a minimal loss of time. References Oral Surgery, St. l,ouis! 1948, The (‘. V. l[osb,v ( lompany, p. 392. 1. Thoma, Kurt H.: Essentials of Oral Surgery. St. T,ouis, 1951, The (1. V. 2. Blair, X7. P., and Ivy, R. H.: Mosbp Company, 11. 1111.
Oral
OF MULTIPLE
Surgery FACIAL
FRACTURES
Report of a Case DAS E. BRANNIN, B.S., D.D.S., M.S.D.,” WILKINSON, D.D.S., M.S.D.,“”
TULSA, OKLA., ASD CHARLES MINNEAPOLIS, MIXY.
1~.
T
HERE are many effective means of treating fractures of the facial bones. However, before one may attempt the care of such conditions he must possess a full understanding of the relationship and function of these structures. When either the maxillae or mandible is involved, a comprehension of jaw function and dental occlusion is an absolute necessity. Thornal states that “injuries of the jaws require highly specialized technical treatment which is directed toward the establishment of normal function of the jaws and teeth, and the prevention of infection and facial disfigurement.” Blair and Ivy2 state that there are two principles which govern the treakment of all fractures: “(1) reduction of the fragments to correct position ; (2) fixation in that position until union occurs.” The simplest method by which these two conditio’ns are met is usually the best. Elaborate and cumbersome external fixation devices are to be avoided if possible. A case report is submitted in which the authors believe that these conditions were fulfilled. Case Report Mr. N. N., a 70-year-old white man, presented at the University Hospital on referral his physician March 23, 1951. He complained of difficulty in eating and speaking. History.-On March 21, 1951, the patient was struck about the head by a horse and rendered unconscious for approximately thirty minutes. He was able to walk as soon as he regained consciousness but experienced pain and difficulty in eating and speaking. The next morning he consulted his physician who told the patient that his lower jaw was fractured. The patient was then referred to the University Hospital for treatment. There was no history of any previous serious illness or operations. A thorough review of past medical history was noncontributory. Examination.-The patient was a 70-year-old well-developed white man who was somewhat disoriented but cooperative. He appeared to have suffered severe trauma to the face. Externally, there was diffuse and intense ecchymoses in the periorbital areas. Further marked ecehymoses were observed in the left cheek, right cheek, neck, and anterior chest (Fig. 1). There was a superficial abrasion of the right ear and cheek. A .from
From The Department of Oral Surgery, Sch~~olIIf Dentistry. 1:niversity of Minnesota. *Clinical Fellow in Oral Surgery. **Clinical Instructor in Oral Surgery.
I+‘ifi’. l.--Preuyel,ati\.,,
Vit,\\ of’ ix+tient t:Vu clays after
ailnlissiun
tu tht: Il~x+i,it:tl.
Examination of the tretll rrvraletl the ~~~iif~~lihd:~r left first l~~molar alltl cuspitl to lw The mantlilmlar right. first premolar and third molar were present as residual quite mobile. Tn the maxillary arch, the maxillary roots. No other teeth were pr(‘sent in the mandible. left central incisor, lateral incisor, cuspitl, lirst molar, and sec*ond molar were present. Also present were the maxillary right central incisor, lateral incisor, cuspi(l, first premolar, These teeth were all to varying degrees loose first molar, second molar, and third molar. as the result of advanced periodontoclasia. Consultations from the Internal hlr(licinc~ and the Neurology services revealed no The general physical condition of the patient was good. evidence of further complications. Roentgenographic Data.-- AU occlusal view of the mandil,ular nymphpsis revealell two overriding fragmentti (Fig. 2). 9 \Vatcsrx’ Gttu3 vic\v of thr skull revraled a fracture of the right infraorllital ridge and separatiull of t.11~ frollto~.?-glllrlatic suture (Fig. 3). A posteroanterior radiograph of the skull further demonstrated separation of the nasofrontal sutures, vertical displacement of the mandibular fragments, and a frarture of the right
TREATMENT
OF XULTIPLE
core:ooid process. The distal fragment of later *al jaw radiographs gave 70 further strat ;ed no displacement of the zygomatic ture line extending superiorly from the left Laboratory and
hemoglobin,
Data.-Blood 13.9 Gm.
Fig. 2.--<)cclusal fract wed mandible. Fig. 3.-Waters’ ridge and separation
view
A
1263
FRACTURES
Oblique the coronoid process was not visible. information. A submentovertical view demonarches. Periapical radiographs revealed a fracfirst molar area.
studies revealed: erythroeytes, differential leukocyte count
roentgenogram
sinus view of the right
FACIAL
Fig.
2.
Fig.
3.
demonstrating
radiograph which reveals frontozygomatic suture.
3,680,000, leukocyte gave the following
displacement a fracture
of of the
fragments right
9, 4,350, result:
of
the
infr ‘aorbital
1264
Fig. Fig. frag :ments
Fig.
4.
Fig.
5.
mandible showing the displaced fra 4.- -l!h :posure of the fractur~~rl of the reducer1 fracture with stainless steel 5.- -DE monstration in PIe ce.
s. holding
the
TREAThtENT
OF ,\ITJLTII’LE
FACIAT,
1265
FRACTURES
neutrophiles,
63, lymphocytes, 29, monocytes, 6, eosinophiles, I, and basophiles, 1. The hem atocrit was 38. Bleeding and clotting times were four minutes each. 1.617, reaction, A, albumin, 0, sug ‘ar 0, Urine studies revealed: specifc gravit,v, eryt hrocytes, 0, and casts 6. Fig. 6.
Fig. 7. Fig. B.--Skin closure of the submandibular incision. Fig. ‘I.-Stainless steel wire passed through a hole in the left infraorbital
ridge.
Treatment From the time of admission the patient had received 100,000 units of aqueous penicilli n every four hours. First Operation.-On March 26, 1951, under Monocaine-epinephrine local anest he&a, mandibular teeth and residual roots were removed. The patient with tstood the remaining the procedure well.
F’ip. fracture
Fig.
8.-Postogerativi~ o~~~lus~l view held in position by two stainless
Fig. 9.--Posteroanterior attached to the maxillary
arch
view bar.
9
roentgenogram dtvnonstmting steel n-ires. roentgenoprwm demonstrating the
the reduced internal
mandibul:rr
transfacial
wires
The anterior submandiI,ulx~, right I e~nporal, and left, infraorbital areas were prepared by first scrubbing t,hern with tincture of green soap followed by tincture of Zephiran An incision was made 1 cm. below the mandible and Chloride. The head was draped. parallel to its lower horder, extending from the left lateral inrisor area to the right
second premolar area. By means of sharp and blunt dissection, the fragments were exposed (Fig. 4). A careful debridement of the area was accomplished. Two through-and-through burr holes, one above the other, were made in each fragment. The fragments were well approximated and retained in place by two stainless steel Z-gauge wires inserted through these holes and crossing each other (Fig. 5). The tissues were approximated with 000 catgut sutures subcutaneously and 0000 silk sutures superficially (Fig. 6). An incision was in the then made 2 cm. posterior to the right eye, extending for 2 cm. superoinferiorlp area of the zygornatie process of the frontal bone. The underlying bone was exposed and a through-and-through burr hole was made in thr bone with a Xo. 3 round burr. Hy stainless steel n-vir
E’ig.
lU.--\-ie\v
of tl:r l,aticnt
three
months
postoyrratively.
infraorbital ridge exposed. A “i-gauge stainless steei wire was introduced (k’ig. ‘i), in the same manner as previously described, to the mucobuccal fornix in the region of the left maxillary first molar. An arch bar was fashioned and secured to the remaining maxillary teeth after the right maxillary first and second premolar residual roots were removed. The stainless steel wires, which at this time were extending int,o the mouth, were secured to the arch wire, and after the maxillary fracture was thus reduced they retained it in correct position. The intraoral wound of the compounded fracture was closed with 000 silk sutures. A pressure bandage consisting of fluffed gauze squares, held firmly in place with two ACE bandages, was then applied to the submandibular and right temporal areas. This bandage also served as a chin support. A light bandage was placed over the left eye. An obtundent eye ointment had earlier been placed under the lid and The patient tolerated the procedure well and was the eye covered with an eye pad. awakening when taken from the operating room.
the immediate Postoperative Course.- ~~The patient 1%as marl13 c:o~~~forta)Jle Ituriug postoperative period wit,h codeine phosphate? I gr. every four hours, as needed. His right eye was swollen and shut the first and scco1~~1lmstoperatirr days but he was able to read on the third postoperative day. The sutures were removed 0x1 the third day and the pressure bandages dispensed with. Postoperative radiographs demonstrated the fragments to be well positioned (Figs. S and 0). The patient was placed on a soft, light protein diet supplemented bp vitamills. The Urology 1)epartment was Postoperatively the patient was unable to void. collsllltrcl and it wa> fount1 tllat he had a hy-pcrtrophied prostate gland n-hich was rr~mov~l Iry t ransurethral resection t hrpe weeks after tlrrl oral surgical procedure:* were carried out. HV was sent home to return May 17, 1951. for remora1 of the wires supporting the maxillae.
Second Operation.-On &lay 18, 1931, the patient was agail taken to the operating room. being premeditated with atropintl sulfate I/lao gr., and morphinrh sulfate, I,$ gr. The right temporal area was infiltrated with procaine, 1 per cent, and epinephrincl, 1:X,000. An extraoral block of the maxillary and mandibular divisions of the right trigeminal nerve was then carried out. The approach was made through the mantlibnlar notch. Thts The wire was wire in this area was exposed by following the previous line of incision. The wound was closed as in the detached from the bone and drawn into the: mouth. previous operation. After local infiltration and an infraorbital nerve l~loclr, a similar procedure was tlonc on the left infraorbital arc’a. Postoperative Course.--The patient was ambnlatoq within six hours after t,he procedure and comfortable throughout the immediate postoperative period. The sutures were removed forty-eight hours postoperatively and the patient sent home the third day. (Xnical and radiographic examinations He returned July 24, 1951, for a final checkup. demonstrated a firnl union of the previously fractured bones. He xvas referred to his teeth ant1 the construrtion of local dentist for extraction of the remaining maxillar) artificial denture,< (Fig. ln1.
Comment 13~ the open reduction of the mandibular fracture and by internal fisation of the upper face fractures, the patient was spared cumhcrsome external iIdjWtmellts anal careful surveillance of apparatus for fixation. Postopcratire Except for the derelopmrnt of urethral ohthe patient were unnecessary. struction postoperatively the patient could ha,vr resumed his normal dut,ies with a minimal loss of time. References Oral Surgery, St. l,ouis! 1948, The (‘. V. l[osb,v ( lompany, p. 392. 1. Thoma, Kurt H.: Essentials of Oral Surgery. St. T,ouis, 1951, The (1. V. 2. Blair, X7. P., and Ivy, R. H.: Mosbp Company, 11. 1111.