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VIII. Fracture cases treated by means of internal fixation
S’L’ERSAL
fixation !)j!~CUIS of ~I~MIISOS~~~LIS wiring or by the use of small metacarpal bone plates with four screws is rrcommended in unstable Cracfractures. They are generally used with tures ancl especiallp in com~linated open reduction. which gives an opportunity for correct positioning of the fragInents. Both bone plates ant1 transosseous and circumferential wires give ver\ They should be applied to fix the .fra;zsittisfactory results if used correctly. relents in their reducetl position, but sI~oulil not be relied upon to rrsisl the strain produced 11~thr Inoviiig of the jaw durirl g mastica,tion or speech. In ali cases the mandible shor~ltl be immobilized. either by intermaxillar!wiring ik In some edeiitulous eases. the teeth are adeqlmte, or h\- the use of a splint. skeletal fixation may he used. Stainless steel wires and Gtallium bone plates are biologically inert and do not ha\:e to be removed after the fracture has united. This does not apply to circumferential wires, since they project, into the rllcuth and therefore must not remain.
Case 160 racture Treated ith fXrcumferentia1 Wiring and Intermaxillary Fixation ri. I>. ~576”‘30’ -* ,, :I .2ii-~~ear-olti mall, was admitted to the llospital on Ma)27, 1947, with the tliagilohis of C~III~OIIIICI, t+omminutrtl fracture of the mandiblc~. E:levell
days
preGiln
to
i~tliriission
the
ptimt
was
in
aii
antonlohile
awi-
which he recdeiycvl injrlries to the heatl. Ifr was llnv:ilisi’iotls fov a.n IIllco!i!~~iowii period of time. 1Tlw1r arrival to the Ilearrst llospitill, he q&net1 sciomness, bnt was dizzy-, bleetliilg dims the mouth n~icl Icft ear. ILe hat1 ii of the mouth. pajnfnl lump on his head ant1 lacerations (;n the chin ant1 illsitle X-rays of the jaws were taken. Iacerat,iotls vleunsctl alItI sutured, two tee1/: wired on the left lower *jaw, penicillin administered, and a Barton bandage allp?ied. The patient remained in the hospital for seven days, the first two of which bleeding from the mouth, sore t,hroat, and difficulty in swallowing and talking persisted. He was referred to this hospital T&h complaints of swelling and a smaii amount of pain. Examination revealed a well-developed, well-nourished man with an 8 by IO cm. swelling about the middle of the lower border and lateral surface of the 90 iivnt
ill
FRACTURES
TREATED
BY
INTERNAL
91
FIXATxQN
left mandible. Mobility and crepitus were present in the left first molar area. Lacerations of the mucous membrane of the lower lip and tongue were present. Roentgenograms showed a compound, comminuted fracture of the left body of the mandible through the first molar space, with butterfly comminution on the lower border. Vertical and lateral displacement were present. On May 29 in the Outpatient Clinic, under local anesthesia, a Jelenko splint was attached to the upper jaw, with wires attached to each tooth for complete stabiliz’ation. In the evening of the sa.me day, under gas-oxygen-ether anesthesia, the wire which had bmeenattached to the. premolars was removed, after which a Jelenko splint was wired to the lower teeth. A circumferential wire was then inserted to hold the comminuted portion of the mandible in position. The rough edges of the lip and tongue wounds were cut and sutured with dermalon sutures. The lower jaw was fixed by intermaxillary wiring connecting the upper and lower splints, a,fter which the patient was returned to his room.
Fig. 97.-Postoperative fragment at lower border lary fixation to immobilize
x-ray showing cornminuted fixed with circumferential wire. the jaw.
fracture Jelenko
of mandible splints used
with butterfly for intermaxil-
Postoperative x-rays showed a cornminuted fracture of the horizontal ramus of the left mandible, held in good position by intermaxillary fixation and circumferential wiring about the butterfly fragment (Fig. 97). The patient’s recovery was uneventful, and he was discharged from the hospital five days after operation. The splint and circumferential wire were removed after six weeks.
Case 161 Multiple Mandibular April
Fractures Treated With Skeletal and Internal
Fixation
L. T. (571621), a X-year-old woolen mill worker, entered the hospital 18, 1947, with a dia.gnosis of multiple fractures of the face.
on
32
‘THOMA,
iHOLLAND,
JR.,
VPWXX~G-RY,
BURROW,
AND
SLXEPEZZ
Twelve days ago? while working at iilis machine in the -iaetory, the patient stated that. his arm got caught in a fan belt and when he regained consciousness he was being taken to a hospital. He was unconscious for a period of approximately fifteen minutes. At his, local hospital, the patient was given emergency treatment for superficial lacerations and bruises. He stated that during his stay at the hospital he did not suffer from dizzy spells, anorexia, or insomnia, and his reflexes were apparently normal. He was able to take soft foods and liquids by mouth without difficulty. Many x-rays were taken, and penicillin therapy was discussed, but nothing was done at the time, and he was referred to the Massachusetts General Hospital for further treatment. Upon admission, the patient’s chief complaint was numbness over his entire face and a.n occasional severe “stretching sensation” of the lower jaw. Physical examination revealed a well-nourished, well-developed man in moderate distress related to his facial injury. There was evidence of a sutured laceration in the right temporal region. There was a large ecchymotic area extending from the right infraorbital region to the lower jaw and from the anterior portion of the neck to the sternum. The buccal and gingival mucosa on the right side also showed evidence of eechymosis. There was numbness but no paralysis of the soft tissues in the infraorbital, maxillary, and mandibular areas. Tenderness was present over the right and left maxillary sinuses and over the right, zygoma and preauricular areas. Intraoral examination revealed the patient to be edentulous, and the left side of the body of the mandible was fractured and markedly displaced upward without being compounded. Preoperative x-rays revealed a comminuted fracture involving the left mandible, with a comminuted fracture through the right ascending ramus of the jaw. The symphysis and the right mandible were displaced downward and toward the left. The condyles were not affected. There was a fracture through the right frontomalar articulation and a fracture of the rim of the right orbit extending downward through the malar bone to involve the lateral wall of the There was also a fracture through the zygomatic arch, with reright antrum. sultant inward and downward displacement. of the lateral portion of the malar bone. Penicillin was administered immediately, 25,000 units every three hours, and consultations were requested from the neurology and eye and ear services, since the paGent had had a period of unconsciousness at the time of his accident, and he now complained of diminished vision in his right eye. The neurological examination was negative, and examination of the right eye suggested damage to the optic nerve from hemorrhage within the nerve sheath, or from X-rays of the optic foramen showed it was direct injury by possible fracture. not involved by the fracture, and it was decided that the operation for reduetion and fixation of the mandibular fractures should be done at. .this time. On April 21, 1947, under gas-oxygen-ether intratracheal anesthesia and after the usual preparation of the face and mouth, a three-inch incision was made below the inferior border of the left mandible. The subcutaneous tissue
FRACTURES
TREATED
BY
INTERNAL
93
FIXATION
was divided, the external maxillary artery was dissected free, tied, and cut, after which the periosteum was incised and the fracture site exposed. There was a lbutterfly fragment at the inferior border which in itself had split in half. A bone plate was placed aeross the main fracture and attached with two screws. The two small pieces of the butterfly fragment were attached with a stainless steel wire. The fracture was very insecure though in good position, and, therefore, skeletal fixation was applied for further immobilization (Fig. 98). The incision was closed in layers. Periosteum and subcutaneous tissues were united with catgut. The skin was closed with interrupted dermalon sualong the anterior.border of the tures. Next an incision was made intraorally right mandibular ramus. The bone was exposed so that the fracture came into view. Three fragments were seen, including the coronoid process. A drill hole was made through the two anterior fragments which were fixed by means of a stainless steel wire. The fracture of the condyloid process could not be reached from this approach, but it looked in fairly good position (Fig. 99). The incision in the mucosa @as closed with interrupted catgut sutures. The third fracture of the malar bone was then reduced by means of a cow horn forceps, which was insert.ed through the skin so as to take hold of the malar bone for manipuThe zygomatic arch, which was fractured in two places, was manipulation. lated to restore its normal contour. A Barton bandage was applied with the patient’s dentures inserted to serve as a splint.
Fig.
98.--Postoperative
x-ray with
of left Sherman
mandibk showing fracture after plate and Frac-Sure appliance.
reduction
and
fixation
The patient was given 1,500 C.C.dextrose in water during tlze operation, and another 1,500 C.C. the next day. Penicillin, 25,000 units every three hours, was continued through the fifth postoperative day. X-rays of the jaw after reduction with internal fixation and Frac-Sure splints showed good position of the reduced bones (Figs. 98 and 99).
The postoperative course was uneventful3 and on May 1, 1947, the _uatienG was discharged with instructions to report back at weekly intervals. The external appliance was removed after five weeks when the patient had good fnncConing of the jaw.
Fig. SS.-Postoperative
Malunited
x-ray of right mandibk and fixed with internal
Fractur
showing multiple fractures transosseous wiring.
of x’arnus
!cduCed
ion and Traumatic
E. F. ,(573786), a 49-year-old executive, entered the hospital on May 6, 1947, for the revision and reduction of an old jaw fracture. Five months prior to this time, he sustained jaw and head injuries resulting from an automobile accident. Ee was treated at a local hospital for lacerations of the chin ; during his subsequent six weeks’ stay at the hospital, itll intraoral incision and drainage was done and intermaxillary wires were applied to his teeth for immobilization of his jaws as x-rays had revealed a, bilateral mandibular fracture. When, after eight weeks, the intermaxillary wires were removed, the pat,ient could not open his jaw. He consulted his dentist who preferred to post,pone He then went to any further treatment until his “symptoms had subsided.” another doctor who x-rayed his teet,h and jaws, and referred him to the Massachnsetts General H’ospital for fnrther treatment five months after his first operation. Examination at the time of admission revealed a well-nourished, welldeveloped man ill moderate distress related to his old jaw fracture. There was a definite protrusion of the mandible, with deflection to the left, and a malocclusion of the anterior teeth (Fig. 100). He suffered from severe pain due to
FRACTURES
TREATED
BY
INTERNAL
Y5
FIXATION
traumatic arthritis of the left temporomandibular joint which began at the time of the accident. His right temporomandibular joint had also recently become involved. X--ray examination revealed a malunited fracture of t.he left body of the mandible, near the angle (Fig. 101, A). The anterior segment on palpation was medially placed. The right side showed a fracture of the body of the mandible in the premolar area which was in fairly good position (Fig. 101, B).
:Fig.
iOO.-Abnormal
occlusion
due to malunion
of double
mandibular
A.
Fig.
101.--A,
Malunited
fracture.
B.
fracture
at angle of jaw. B, Fracture edentulous mandible.
in first
molar
region
of partly
The patient was started on penicillin, 50,000 units every three hours, and on May 7, 1947, under gas-oxygen-ether intratracheal anesthesia, induced with pentothol, and after the usual preparation of the skin of the neck and face, an in-
96
TBQMA,
HOLLANZ),
JR,
WUQDBURY,
BUERQW,
AND
SLEEFER
cision was made one inch below the inferior border of the mandible, extending from the angle of the jaw 2.5 inches forward. The subcutaneous tissue was divided as was the platysma after which the external maxillary artery and facial vein were dissect.ed free, divided, and tied. The periosteum wa,s then incised and the site of the fracture exposed. The fragments seemed to have overlapped, and hea.led with the ramus overriding on the external surface of the
Fig.
lOa.-Postoperative
Fig.
103.-X-ray
dible
x-ray showing fracture immobilized by means
taken
five
months
after
revised ancl fixed of intermaxillary
revision
of fracture
with Sherman wiring.
showing
excellent
plate.
Marl-
~lnion.
horizontal part of the jaw. With the osteotome, the two fragments were cleaved apart, after which the ends were freshened, cutting away considerable eburnated bone. The fragments were repositioned to bring the teeth in normal oeclusion. After the bone was realigned, a four-hole Sherman plate was attached by means of four screws. Chips derived from the excised bone were placed between the fragments. The periosteum was then replaced and sutured, and
FRACTURES
TREATED
BY
INTERNAL
FIXATION
97
the wound closed in layers, the skin by means of interrupted dermalon sutures. After applying a dressing on the wound, the mouth was opened, the left upper second incisor root extracted, and intermaxillary wiring applied to immobilize the jaws, after the patient’s occlusion had been properly adjusted. The postoperative x-rays showed excellent alignment (Fig. 102). His course from then He was instructed to report until discharge on May 11, 1947 was unevent,ful. back for the removal of the wires and further postoperative care. The intermaxillary fixation was dispensed with after six weeks. A postoperative x-raJ taken five and one-half months after revision of the fracture is shown in Fig. 103.
fixation !)j!~CUIS of ~I~MIISOS~~~LIS wiring or by the use of small metacarpal bone plates with four screws is rrcommended in unstable Cracfractures. They are generally used with tures ancl especiallp in com~linated open reduction. which gives an opportunity for correct positioning of the fragInents. Both bone plates ant1 transosseous and circumferential wires give ver\ They should be applied to fix the .fra;zsittisfactory results if used correctly. relents in their reducetl position, but sI~oulil not be relied upon to rrsisl the strain produced 11~thr Inoviiig of the jaw durirl g mastica,tion or speech. In ali cases the mandible shor~ltl be immobilized. either by intermaxillar!wiring ik In some edeiitulous eases. the teeth are adeqlmte, or h\- the use of a splint. skeletal fixation may he used. Stainless steel wires and Gtallium bone plates are biologically inert and do not ha\:e to be removed after the fracture has united. This does not apply to circumferential wires, since they project, into the rllcuth and therefore must not remain.
Case 160 racture Treated ith fXrcumferentia1 Wiring and Intermaxillary Fixation ri. I>. ~576”‘30’ -* ,, :I .2ii-~~ear-olti mall, was admitted to the llospital on Ma)27, 1947, with the tliagilohis of C~III~OIIIICI, t+omminutrtl fracture of the mandiblc~. E:levell
days
preGiln
to
i~tliriission
the
ptimt
was
in
aii
antonlohile
awi-
which he recdeiycvl injrlries to the heatl. Ifr was llnv:ilisi’iotls fov a.n IIllco!i!~~iowii period of time. 1Tlw1r arrival to the Ilearrst llospitill, he q&net1 sciomness, bnt was dizzy-, bleetliilg dims the mouth n~icl Icft ear. ILe hat1 ii of the mouth. pajnfnl lump on his head ant1 lacerations (;n the chin ant1 illsitle X-rays of the jaws were taken. Iacerat,iotls vleunsctl alItI sutured, two tee1/: wired on the left lower *jaw, penicillin administered, and a Barton bandage allp?ied. The patient remained in the hospital for seven days, the first two of which bleeding from the mouth, sore t,hroat, and difficulty in swallowing and talking persisted. He was referred to this hospital T&h complaints of swelling and a smaii amount of pain. Examination revealed a well-developed, well-nourished man with an 8 by IO cm. swelling about the middle of the lower border and lateral surface of the 90 iivnt
ill
FRACTURES
TREATED
BY
INTERNAL
91
FIXATxQN
left mandible. Mobility and crepitus were present in the left first molar area. Lacerations of the mucous membrane of the lower lip and tongue were present. Roentgenograms showed a compound, comminuted fracture of the left body of the mandible through the first molar space, with butterfly comminution on the lower border. Vertical and lateral displacement were present. On May 29 in the Outpatient Clinic, under local anesthesia, a Jelenko splint was attached to the upper jaw, with wires attached to each tooth for complete stabiliz’ation. In the evening of the sa.me day, under gas-oxygen-ether anesthesia, the wire which had bmeenattached to the. premolars was removed, after which a Jelenko splint was wired to the lower teeth. A circumferential wire was then inserted to hold the comminuted portion of the mandible in position. The rough edges of the lip and tongue wounds were cut and sutured with dermalon sutures. The lower jaw was fixed by intermaxillary wiring connecting the upper and lower splints, a,fter which the patient was returned to his room.
Fig. 97.-Postoperative fragment at lower border lary fixation to immobilize
x-ray showing cornminuted fixed with circumferential wire. the jaw.
fracture Jelenko
of mandible splints used
with butterfly for intermaxil-
Postoperative x-rays showed a cornminuted fracture of the horizontal ramus of the left mandible, held in good position by intermaxillary fixation and circumferential wiring about the butterfly fragment (Fig. 97). The patient’s recovery was uneventful, and he was discharged from the hospital five days after operation. The splint and circumferential wire were removed after six weeks.
Case 161 Multiple Mandibular April
Fractures Treated With Skeletal and Internal
Fixation
L. T. (571621), a X-year-old woolen mill worker, entered the hospital 18, 1947, with a dia.gnosis of multiple fractures of the face.
on
32
‘THOMA,
iHOLLAND,
JR.,
VPWXX~G-RY,
BURROW,
AND
SLXEPEZZ
Twelve days ago? while working at iilis machine in the -iaetory, the patient stated that. his arm got caught in a fan belt and when he regained consciousness he was being taken to a hospital. He was unconscious for a period of approximately fifteen minutes. At his, local hospital, the patient was given emergency treatment for superficial lacerations and bruises. He stated that during his stay at the hospital he did not suffer from dizzy spells, anorexia, or insomnia, and his reflexes were apparently normal. He was able to take soft foods and liquids by mouth without difficulty. Many x-rays were taken, and penicillin therapy was discussed, but nothing was done at the time, and he was referred to the Massachusetts General Hospital for further treatment. Upon admission, the patient’s chief complaint was numbness over his entire face and a.n occasional severe “stretching sensation” of the lower jaw. Physical examination revealed a well-nourished, well-developed man in moderate distress related to his facial injury. There was evidence of a sutured laceration in the right temporal region. There was a large ecchymotic area extending from the right infraorbital region to the lower jaw and from the anterior portion of the neck to the sternum. The buccal and gingival mucosa on the right side also showed evidence of eechymosis. There was numbness but no paralysis of the soft tissues in the infraorbital, maxillary, and mandibular areas. Tenderness was present over the right and left maxillary sinuses and over the right, zygoma and preauricular areas. Intraoral examination revealed the patient to be edentulous, and the left side of the body of the mandible was fractured and markedly displaced upward without being compounded. Preoperative x-rays revealed a comminuted fracture involving the left mandible, with a comminuted fracture through the right ascending ramus of the jaw. The symphysis and the right mandible were displaced downward and toward the left. The condyles were not affected. There was a fracture through the right frontomalar articulation and a fracture of the rim of the right orbit extending downward through the malar bone to involve the lateral wall of the There was also a fracture through the zygomatic arch, with reright antrum. sultant inward and downward displacement. of the lateral portion of the malar bone. Penicillin was administered immediately, 25,000 units every three hours, and consultations were requested from the neurology and eye and ear services, since the paGent had had a period of unconsciousness at the time of his accident, and he now complained of diminished vision in his right eye. The neurological examination was negative, and examination of the right eye suggested damage to the optic nerve from hemorrhage within the nerve sheath, or from X-rays of the optic foramen showed it was direct injury by possible fracture. not involved by the fracture, and it was decided that the operation for reduetion and fixation of the mandibular fractures should be done at. .this time. On April 21, 1947, under gas-oxygen-ether intratracheal anesthesia and after the usual preparation of the face and mouth, a three-inch incision was made below the inferior border of the left mandible. The subcutaneous tissue
FRACTURES
TREATED
BY
INTERNAL
93
FIXATION
was divided, the external maxillary artery was dissected free, tied, and cut, after which the periosteum was incised and the fracture site exposed. There was a lbutterfly fragment at the inferior border which in itself had split in half. A bone plate was placed aeross the main fracture and attached with two screws. The two small pieces of the butterfly fragment were attached with a stainless steel wire. The fracture was very insecure though in good position, and, therefore, skeletal fixation was applied for further immobilization (Fig. 98). The incision was closed in layers. Periosteum and subcutaneous tissues were united with catgut. The skin was closed with interrupted dermalon sualong the anterior.border of the tures. Next an incision was made intraorally right mandibular ramus. The bone was exposed so that the fracture came into view. Three fragments were seen, including the coronoid process. A drill hole was made through the two anterior fragments which were fixed by means of a stainless steel wire. The fracture of the condyloid process could not be reached from this approach, but it looked in fairly good position (Fig. 99). The incision in the mucosa @as closed with interrupted catgut sutures. The third fracture of the malar bone was then reduced by means of a cow horn forceps, which was insert.ed through the skin so as to take hold of the malar bone for manipuThe zygomatic arch, which was fractured in two places, was manipulation. lated to restore its normal contour. A Barton bandage was applied with the patient’s dentures inserted to serve as a splint.
Fig.
98.--Postoperative
x-ray with
of left Sherman
mandibk showing fracture after plate and Frac-Sure appliance.
reduction
and
fixation
The patient was given 1,500 C.C.dextrose in water during tlze operation, and another 1,500 C.C. the next day. Penicillin, 25,000 units every three hours, was continued through the fifth postoperative day. X-rays of the jaw after reduction with internal fixation and Frac-Sure splints showed good position of the reduced bones (Figs. 98 and 99).
The postoperative course was uneventful3 and on May 1, 1947, the _uatienG was discharged with instructions to report back at weekly intervals. The external appliance was removed after five weeks when the patient had good fnncConing of the jaw.
Fig. SS.-Postoperative
Malunited
x-ray of right mandibk and fixed with internal
Fractur
showing multiple fractures transosseous wiring.
of x’arnus
!cduCed
ion and Traumatic
E. F. ,(573786), a 49-year-old executive, entered the hospital on May 6, 1947, for the revision and reduction of an old jaw fracture. Five months prior to this time, he sustained jaw and head injuries resulting from an automobile accident. Ee was treated at a local hospital for lacerations of the chin ; during his subsequent six weeks’ stay at the hospital, itll intraoral incision and drainage was done and intermaxillary wires were applied to his teeth for immobilization of his jaws as x-rays had revealed a, bilateral mandibular fracture. When, after eight weeks, the intermaxillary wires were removed, the pat,ient could not open his jaw. He consulted his dentist who preferred to post,pone He then went to any further treatment until his “symptoms had subsided.” another doctor who x-rayed his teet,h and jaws, and referred him to the Massachnsetts General H’ospital for fnrther treatment five months after his first operation. Examination at the time of admission revealed a well-nourished, welldeveloped man ill moderate distress related to his old jaw fracture. There was a definite protrusion of the mandible, with deflection to the left, and a malocclusion of the anterior teeth (Fig. 100). He suffered from severe pain due to
FRACTURES
TREATED
BY
INTERNAL
Y5
FIXATION
traumatic arthritis of the left temporomandibular joint which began at the time of the accident. His right temporomandibular joint had also recently become involved. X--ray examination revealed a malunited fracture of t.he left body of the mandible, near the angle (Fig. 101, A). The anterior segment on palpation was medially placed. The right side showed a fracture of the body of the mandible in the premolar area which was in fairly good position (Fig. 101, B).
:Fig.
iOO.-Abnormal
occlusion
due to malunion
of double
mandibular
A.
Fig.
101.--A,
Malunited
fracture.
B.
fracture
at angle of jaw. B, Fracture edentulous mandible.
in first
molar
region
of partly
The patient was started on penicillin, 50,000 units every three hours, and on May 7, 1947, under gas-oxygen-ether intratracheal anesthesia, induced with pentothol, and after the usual preparation of the skin of the neck and face, an in-
96
TBQMA,
HOLLANZ),
JR,
WUQDBURY,
BUERQW,
AND
SLEEFER
cision was made one inch below the inferior border of the mandible, extending from the angle of the jaw 2.5 inches forward. The subcutaneous tissue was divided as was the platysma after which the external maxillary artery and facial vein were dissect.ed free, divided, and tied. The periosteum wa,s then incised and the site of the fracture exposed. The fragments seemed to have overlapped, and hea.led with the ramus overriding on the external surface of the
Fig.
lOa.-Postoperative
Fig.
103.-X-ray
dible
x-ray showing fracture immobilized by means
taken
five
months
after
revised ancl fixed of intermaxillary
revision
of fracture
with Sherman wiring.
showing
excellent
plate.
Marl-
~lnion.
horizontal part of the jaw. With the osteotome, the two fragments were cleaved apart, after which the ends were freshened, cutting away considerable eburnated bone. The fragments were repositioned to bring the teeth in normal oeclusion. After the bone was realigned, a four-hole Sherman plate was attached by means of four screws. Chips derived from the excised bone were placed between the fragments. The periosteum was then replaced and sutured, and
FRACTURES
TREATED
BY
INTERNAL
FIXATION
97
the wound closed in layers, the skin by means of interrupted dermalon sutures. After applying a dressing on the wound, the mouth was opened, the left upper second incisor root extracted, and intermaxillary wiring applied to immobilize the jaws, after the patient’s occlusion had been properly adjusted. The postoperative x-rays showed excellent alignment (Fig. 102). His course from then He was instructed to report until discharge on May 11, 1947 was unevent,ful. back for the removal of the wires and further postoperative care. The intermaxillary fixation was dispensed with after six weeks. A postoperative x-raJ taken five and one-half months after revision of the fracture is shown in Fig. 103.