CHAPTER XXYIII. (Part 3)

Amer. Med. Assii., Apr. 9, 1910. 370 FRACTURES AND DISLOCATIONS quite as secure as Oliver's method and it is not possible to release the jaws as quickly in case of emergency. Angle's hands and wire. — In place of the anchor loops described in Oliver 's method we may employ Angle 's bands such as shown in Fig. 510, They are ordinarily used in orthodontia but serve the purpose in fractures very nicely. They may be obtained at dental supply houses and the knobs for securing the traction wire may be attached to the band at any point desired by means of solder. Fig. 507. — Simple method of wiring the upper to the lower teeth in fracture of the lower jaw. This is the same method as demonstrated in Figs. 503, 504, 505 and 506. Fragments held in good apposition in spite of dental deficiencies. Loops instead of knobs are sometimes used on the bands and are very satisfactory. Threaded bars and jack-screws are made to pass from an Angle band on one of the lower teeth to be anchored on a band placed on one of the teeth in the opposite arcade, but these should never be used since the jaws cannot be released quickly with wire cutting forceps in case of emergency. The Angle splint will be considered under the next heading. 6. Seciinng the fragments by means of wiring the teeth of the lower jaw. — Various modifications of this principle have been FRACTURES OF LOWER JAW 371 devised and in many instances the method is thoroughly satis- factory. An extremely old and sometimes efficient method is that of wiring the adjoining teeth. A loop of heavy wire is passed about four teeth (two on either side of the fracture) and the ends twisted tightly together, cut off and bent inward between the teeth so as not to injure the mucous membrane. It is usually difficult to set this wire sufficientlv tight bv twisting and when Fig. 508. Fig. 509. Fig. 508. — Angle's bands and bars applied to fracture of the mandible at the symphysis. Fig. 509. — Angle's bands and bars applied to fracture of the mandible between the second bicuspid and first molar. Fig. 510. — Angle's bands with knobs for wiring jaws together. Fig. 511. — Same case as shown in Fig. 510 showing opposite side of jaw with points of fixation on either side of fracture. such is the case a racking wire is passed between the teeth so as to include both arms of the loop. The ends of this wire are twisted tightly together and in so doing the internal arm of the loop is snugged up against the lingual surface of the teeth. The wire must include at least two teeth on each side of the fracture; if only one tooth on each side is included they will almost surely loosen, the object of fixation thus being de- 372 FRACTURES AND DISLOCATIONS feated. A more secure method of wiring the teeth together is described by Oliver in the first part of his procedure (page 367). Any form of wiring must be closely watched and tightened to compensate for the loosening which is sure to take place. For this reason silver wire is not as satisfactory as some other forms on account of the likelihood of its breaking when much twisting is required. Bronze-aluminum wire of large caliber or ordinary electric wire, with the insulation removed, may be used. In any event the wire should be heavy and the ends pointed to facilitate its passage between the teeth. If it is desired to pass wire between the teeth where there is not sufficient space an opening may be made slightly below the gums by puncturing with a sharp instru- ment; this however is very rarely necessary. Wiring will have to be varied according to the nature and disposition of the teeth. When there is much tendency toward lateral displacement this method should not be employed; it is particularly inefficient when the line of fracture through the body is oblique, so that one frag- ment tends to slip past the other. Hammond's wire splint, a method which has been followed by good results, consists of a heavy iron wire encircling all the teeth. One continuous wire follows the lingual and buccal surfaces of the lower dental arcade. This wire should be heavy enough to with- stand the lateral strain and after fitting it to the teeth it is better to remove it and solder the ends together rather than to depend on simple twisting. With the wire in place about the lower denture a number of copper racking wires of lighter material are passed between the lingual and buccal arms of the splint and the ends twisted to secure the appliance in place. Edmund's forceps (Fig. 500) may be used to force the heavy wire of the splint more snugly against the cervical portions of the teeth and to facilitate tightening the racking wires. This method is usually not secure enough to allow motion of the jaw during the after-treatment but should be used in conjunction with some method of fixing the jaws together. Angle's splint consists of "bands fastened about the teeth with a threaded bar passing between them. The bands are similar to those used in wiring the jaws together but have heavy tubes soldered to them instead of the knobs. The tubes are placed horizontally on the buccal side and have a heavy threaded bar passing through them from one side of the fracture to the other. FRACTURES OF LOWER JAW 373 When the uuts are placed and tightened the fragments are pulled together and held in firm apposition. The splint may be tightened by passing wire from band to band on the lingual aspect. Fracture of the ramus is a rare condition and is not, as a rule, accompanied by much displacement. Some form of fixing the jaws together will afford the necessary rest for the ramus and will be followed by good results in most cases. When much deformity exists open incision may be indicated to effect reduction. Wiring of the fragments may be called for if there is tendency toward displacement when the jaws are fixed. Fracture of the neck of the condyle, like fracture of the ramus, requires fixation of the jaws, and may require operative intervention if the displacement is pronounced. In operating in this region care must be exercised to avoid injury to Stenson's duct and the facial nerve (see Anat- omy, page 350). Fracture of the coronoid is extremely rare and will probably require only fixation of the jaws for a short time. Operative Treatment. — In some cases it may seem advisable in meeting the requirements of the case in hand to unite the frag- ments of the body of the bone by direct wiring or by the use of a small Lane plate. This is done through an incision parallel to and slightly below the lower border of the jaw. In making this incision care should be taken to avoid the facial artery which crosses the external surface of the bone in an upward and forward direction at the antero-inferior angle of the masseter. The bone having been exposed, holes are drilled in the positions of greatest advantage and wire passed, twisted, cut off and turned in. In oblique fractures with overriding tendency it is often best to have both arms of the loop passing through the plane of fracture in the substance of the bone. In transverse fractures a single loop with one arm on the external and the other on the internal surface of the bone will be sufficient to secure immobilization if the serrated edges of the fragments are well engaged and the wire properly tightened. It is well in any operative procedure about the jaw to refrain from removing loosened teeth and spicules of bone unless entirely separated from the surrounding tissues, since they usually become solid as a result of the free circulation in this region. In some cases of fracture of the jaw we have actual destruction of a con- siderable portion of the bone, and in other cases we have loss of osseous tissue through infection and necrosis and in such instances 374 FRACTURES AND DISLOCATIONS it is difficult to obtain an end result which is perfectly satisfactory. When a portion of the bone is lost good occlusion is not possible and more or less deformity is bound to ensue unless some method other than those previously described is resorted to. In these cases much good can be accomplished by means of bone trans- plantation, although the method has not been sufficiently employed at the present time to state definitely what its limitations may be. However transplantation is justified and indicated, in view of the unhappy results following destruction of a portion of the jaw. The bone transplant is usually taken from some other portion of the patient's skeleton and placed in the mandible according to the principles of bone transplantation laid down in Chapter LX. The usual rules governing union in fractures do not hold good about the face since the free circulation is capable of withstanding greater insult and accomplishes great, rapid and extensive repair. Cases have been reported in recent years showing excellent results following transplantation of bone and what is still more surpris- ing the formation of new bone about metallic framew^ork previously built to fit the reciuirements of the case. This metallic frame- work has even been successful in the forming of a new condyle. The transplant is most easily and satisfactorily obtained from the crest of the tibia; it should be cut to accurately fit the defi- ciency in the jaw\ Its ends must be placed in firm apposition with the freshened, living ends of the maxillary fragments and should be immobilized by wire loops or plates. The transplant must not be exposed within the mouth but should be protected at least by mucous membrane. Transplantation should not be performed in the presence of infection ; it is essential to wait until all dead bone has sloughed out or been removed and the sinuses healed in, before the transplant or any other foreign material is introduced. In closing the incision after operation on the jaw a subcutaneous suture should be run, gathering in considerable tissue between the bone and the skin ; by this means we will avoid the unsightly re- tracted scars so frequently seen following operations on the jaw. The skin is best closed with horse-hair. If suppuration follows the operation we must see to it that drainage is free and complete but we should not be too hasty in removing foreign materials, since discharging sinuses in this region frequently close of them- FRACTURES OF LOWER JAW 375 selves ill spite of the presence of foreign bodies such as suture materials, plates, etc. After-Treatment. — The after-treatment of fracture of the jaw consists ill keeping the mouth clean by means of mild antiseptic washes and seeing to it that the mechanical appliance in use is properly accomplishing its purpose of immobilizing the fragments. When a method is employed which keeps the jaws closed the pa- tient must be fed with liquids ; an aid to the introduction of food will be found in passing a tube between the cheek and the teeth, the end passing- behind the last molar. Eggs and milk will form the main part of the diet. These may be combined in different ways and various flavoring materials used to prevent the patient tiring of them. Soups and broths will add variety. It will usually not be necessary to keep the jaws together for a period longer than ten days or two weeks so that the inconvenience of feeding is not a long one. Union is well under way by this time but the mandible will not be in condition to stand any con- siderable strain until two months or more have elapsed from the time of fracture ; the patient should be cautioned in this regard. Prognosis. — The usual case of fracture of the body of the jaw should be followed by perfect function and no deformity. Cases in which the trauma has been severe and in which there have been multiple fractures are much more difficult to treat and ac- cordingh^ are sometimes followed by more or less loss of function and deformity. Protracted cases and those in which infection has occurred may be followed by damage to the articulation and in some instances ankylosis. The more complications the case pre- sents the worse the prognosis.