-266 Tnn ftiTign 1

MEDICAL JOURNA-L J TREATiNIENT OP V-A-XIMkRY rMICTUIRES., [FED. ID, 1,915

TREATMENT OF MAXILLARY FRACTURES.l foreign bodies as well as fragments of the bones or mis-
placed teeth. The x rays will give very valuiable assist-
ance, and a radioggraph of every extensive case should bo
V. E. KAZANJIAN, D.M.D., taken.
DEMONSTRATO1t IN PROSTHETIC DENTISTRY, HARVARD NITERSITY Treatme',d.
SURGICAL UNIT, FRANCE).
(UARVARD
I will not discuss the care and treatment of the external
TtE subject of maxillary fractures is large, but that pait wound, as that is not essentially different from that of a
of it whichl interests military surgeons is the immediate wound in other parts of the bodcy, but confine mnyself to thle
and effective treatment of cases that come to militiary matter of adjustment and setting of the bony parts.
hospitals as a result of gunshot wounds. The number of Our aim must be to create a comparative immobility of
injuries of the lhead and face is by no means a negligible the parts, ancd to restore the
quantity, and their efficient treatment is somewhat out of functional activity of thle
tlle sphere of the general jaws as far as possible. It
surgeon. It is true, that has been an accepted pme
tlhese cases are raret y fatal, tice in the past, and one |
yet any failure to treat somewhat in use at pre.
tlhem efficiently may be sent, to connect the parts 'j
followed by. serious defor- togetther with wire sutures j
mities of the face and in- or metal plates fastened to
efficient masticatory. power, the bone.s. This method,
with its resultant lowering while nseful in exceptional /
of the resistance of the cases, has some serions ob-
*,? S patient. On tile other jections. It quite often in. -
j hand, immediate treatment terferes with the normal
vwill give very satisfactory occlusion of tlhe teetb, ' S
FIG. 1. results and facilitate sucl creating deformities, and,
Ligation of Teeth with Brass futurle work as plastic as the mouth cannot be
Ligatures. The wires are
- operations intended to re- kept sterile, iinfectio n
passed and twisted around the store tlle functions and spreads, causing additional
necks of different
then the upper and iower teeth
teeth,. and
cosmetic appearance of the complii8ations.
fasteifed together. Blcuspids face and jaws. The oral surgeon, how-
and molars arH wired singly, FFractures of tile maxilla, ever, follows a different
but iheisors and cuspids should
be fastened together in pairs, especially the mandible, method. All the fixation is
as in the diagram, then
follow the same general accomplished by utilizing
attached to the corresponding
teeth of theol)posite jaw. This lines, and their treatment the remaining teeth or roots
method is especially useful for is guided by the same prin and the alveolar ridges,
simple fractures, or fractures assisted by bandages and
with very little displacement ciples as fractures of other
involving the mandible only.
It is not applicable in cases
bones, but certain local
conditions have to be taken
chin and head suppoits.
knowledge of the nor-
OurOurknowledge MNodified
FIG 3a
Vulcanite and Band(
with extens;ive wouinds, which and Wire Splints.-Either of
require more adequate drain- into consideration: mal occlusion of the teeth these is applicable to fractures
age of the mouth than this 1. Tlle mandible is a very gives us an excellent guide. of the mandible, and are espe-
mobile bone, and is sup- This soiould be emphasizedcially usefuil
be
should
emphasized wvhere, theretissues.
tth and contig'uous is loss
ported and controlled by muscles of mastication wbich and followed very faith. The heavy wire bar of the vul-
have very great contractile power. It is exposed and very fully
f no matter how ex- canite
over thesplintlostaffords a bridge
tissues. and
irregular in shape. Fracture of this bone, therefore, is tensive the fracture, or how removes the objection to the
very often associated with considerable displacement of much bony tissue is lost. continuous vulcanite type by
the parts. Otherwise we may create modequate drainage to tho
2. Fractures of tile jaws are alnmost always compound, very serious deformities
and, as the moulth is an ideal nidus for bacterial infection that will upset the symmetry of the facial contour and
and subsequent complications, much is added to the the performance by the jaws and tongue of their normal
difficulty of treatment. function-tlhe efficient mastication of food and proper
3. Beinig the most mobile and exercised bone of the articulation in speeclh.
body, the parts -of a broken It has been customary in the past- to ligate the upper
mandible are very difficuLlt and lower teeth together witl brass wires and support the
to hold together. jaw with bandages, a method whichl, while very simple and
J xThe
1 cases of fracture
jaw we are called upon
of useful in many fractures as seen in civil life, I find of very
little use, as the cases are -
C/ 27/ Z/ \
jR )/2/t \ )
thetreat
to differ widely from
those met with in civil prac-
complicated by external
wounds.
tice. First, -there is an If the fractures are an-
extrnal wound, varying in terior to the last lower
size from a small opening to teeth a simple splint of
a very extensive lacerated vulcanite or metal is made
wound of the face or under and cemented on, fitting
the chin; and, secondly, over the teeth, alloWiDn -'
the fractures are always always room- for drainage
comminuted and often mul- of the wounds of the mouth.
This gives the patient the
Fic. 4.
tiple, involving the upper Intermaxillary ]E lastics.-
FIG. 2. as well as the lower jaw. chance to use the jaws Elastic bands frawing between
B3arton Bandage.-This
form In more severe cases there moderately. The same re- (whichsoldered
hooks to metal bands
are soldered in pairs or
of bandage affords a simaple * . suit is accomplishedC by triples to prevent elongation of
and effective method for re- 15 tos, varying in amount,
ducing downward and forward of bony as well as soft using metal bands around the teeth in their sockets) are
displacement
and holding the
the
two
m&ndible,
jaws in
tissue. Moreover, the in the teethl
the ad connecting
and
teeth conne t' useftul for gradual
displacements
reduction of
of the miandible.
close proximity. The turn jury is rarely confined these witlh heavy wires. Elastics can be applied by this
passing under the
in~ the tideeclt?in 1 solely to the jaws, generally If the fracture is at the method so that force may be
exsrted in any desired direc.
-applied
whlich the force is required.
direction in
involving, in addition, eyes, angle of the mandible or. tion.
ears, nose or pharynx. along the ascending ramus,
There can be lno mistake in diagnosis, but it necessary is the lower jaw is -attached to the upper eitlher by rubber
to ascertain the number of fragments, the directions of bands, silli ligatures, or wires, splints being made accord-
the fractures, the amount of lost tissue, and the location of ingly.
In cases which come uinder treatmnent late tile question
Road at a meoting of the Military Medical Society mentionod in
the BRITISH MEDICAt JOURNAL of December 18th, 1915, P. 905, and.
is, more comnplicated. The external wounds in healing
Vccenmber 25tb, P. 9A38 form Scar tifssu , the dispikeed parts of the bones begin to
 TREATMENT- OF MAXILLARY FRACTURES.
FSEB. I9. 1916J
form union, tlhe muscles of mastication lose their contrac-
tile power, partly owing to want of and partly througlh
use
injury, and ankylosis of temporo-maxillary joints is very
marked. In addition we lhave gross deformity of the face.
In these circumstances the correction must be gradual.
We lhave to fighit against the cicatricial tissues, and that is
always difficult. Mechlanical appliances must necessarily
be more or less complicated, and thle degree of success is
partly proportional to the ingenuity of the oral surgeon,
as new appliances have
to be devised
the demands.
Cases witlh extensive loss
of soft and bony tissues
are comjlaratively difficult
to treat, and it is
sible to outline a class of
FIG. 5. appliances to meet them,
Metal Band and Wire Splint as eaclh lhas its own pecu-
for Maxilla.-A useful retaining
aipliance for fractures of the
li a r .i t y an d should be
upper jaw, whhich has been used handlsYJ accordingly.
successfully in fractures in- lhave, lhowever, certain rules
solving the process carr ying all to
the teeth of the nmaxilla, except dgue us
1. We must try to con-
the two last molars on one side.
trol the infected area
by free drainage and frequent irrigations, etc.
2. No attempt slhould be made to suture the soft parts
with the idea of closing the gap until such time as
permanent -splints are adjusted and union of the bony
fragments is well under way. This rule is practically
universal with all the oral surgeons doing extensive work
of this kind.
3. The. appliance should be made with the intention of
lholding the dissociated parts in their normal positions,
taking as a guide the normal occlusion of the teeth.
Fractures of the superior maxilla are easier to con-
trol than tllose of the
tf~ mandible, as
are more or less firmly
connected with the otlher
cranial bones.
is no displacement, simple
bandaging is
sufficient. More compli-
cated cases are treated
witlh splints made of eitlher
rubber or metal, assisted
-=l by straps passing over the
r top of the lead.
;2 -, ' Care of the Mouth!.-The
care of tlle mouthi is a
'-.,i very important part of tlhe
; 9..41 treatment. It is very foul,
owing to the inability of
the patient to clean it
FIG. 6. properly. The wound,
A form of band and wire always opening into the
spolint, ulsefuil in the reduction m
of multi)le fractures of the mouth, gives a constant
mnandible, where one-piece
a source- of infection,
new
splint is not practicable. lbt so thatprecautions should
affords a method for the
gradual reduction of extensive be taken by frequent
displacement of the broken pack
ing,
parts. not fouind in contintious . .' etc., to prevent
wire splints. (From casts tlle flow of saliva into the
wound.
The following metlhods I lhave found very satisfactory:
1. Tincture of iodine is applied to the gums and teeth
with a small piece of cotton.
2. Pledgets of cotton are saturated with hydrogen
peroxide and rubbed over the teetlh and all the
mucous strfaces-of thle mouth as thloroughly as
possible; this hielps to remove particles of food,
mucus, clots of blood, etc.
3. The mouth is irrigated with an antiseptic fluid.
The nurse slhould be instructed to repeat this treatment
tlhree or four timnes a day, except the use of iodine, which
is applied only two or tlhree times a week.
eomplications.-Fractures of the maxillary bones alone
arerarely fatal, but guLnslhotwounds are seldom limited to
the jaws. The bullet may pass through or lodge itself in
the head or neck, causing serious danmage to the organs
and tissues of the immediate neighbourhiood. We must
not overlook this fact, and the patient shlould he watched
BT
Ir Tur
MEDICAL JOUSNKA 267
very.carefully in the first few days. It is hiiglhly important
to examine the path of the bullet, and determine the
amount of injury done as far as is possible.
The complication most dreaded is sudden haemorrhagge.
This is most common, of course, wlhen the injury is in the
immediate vicinity of good-sized blood vessels, particularly
those of the neck. A verv sliglht flow of blood, either
from the external wounds or tlhe moutlh, shotuld be carefully
followed up. It may be the beginning of a serious
haemorrlha.ge.
to meet
impos-
We
FIG. 7.
Kingsley Bars.-This appliance consists of a vulcanite plate
holding at the sides square metal tubes, for the reception of
squarect heavy wires, which extetnd externally from the corners of
the mouth along the cheeks. The splint is supported by a head
harness connected to the bars. This splint gives an excellent
anchorage from which to work to the mandible, in cases in which
fractures extend to both jaws.
An extensive fracture of tllh superior maxilla may
involve tbe cranial bones and lead to disorders of the
hIglher nerve centres, a possibility which should be
they carefully considered.
Among the minor complications we may expect is
ankylosis. In very many cases thiis is only temporary,
If there duie to the injury of the soft tissues and tlle non -use of the
jaws. Yet if the injury is at the teimiporo-maxillary joint
usually we may lhave serious results if the treatment is not in thle
right direction. To prevent adhesions tlle mobility of tllc
joints should be encouraged.
The control of the inflamnmation, abscesses, and necrosis
of the tissues is part of our general treatument.
Importance of Early Trea vlent.-The imiportance of
early treatment of maxillary fractures cannot be over-
estimated. The appliances slhould be adjusted as soon
as possible, as this assures the quickest andl best result.
I have noticed that on account of the unsightly appear-
ance of the external wound there is a strong temptatioln to
give attention to the wound, to tlle neglect of the- settinig
of the bones. The wound slhouild undotubtedly receive
proper care, but the fundamenltal treatment must begin
with the bony structure. If the patient has a fractured
arm we do not wait several weeks or montlhs before
applying our splints or bandages. Tilis rule lholds equally
true with fractured jaws.
War-time injuries to the jaws, with tlheir attendant
injuries to otlher parts and resulting constitutional dis-
turbances, are best lhandled by the hearty co-operation of
tlle general surgeon and the oral specialist, working
togetlher for the welfare of the patienlt by restoring to himu
as far as possible his normal facial appearance and tle
use of his jaws and teeth in the processes of mastication.
I desire to express my great indebtedness to my friend
and colleague, Dr. F. H. Brigham, of the Harvard Surgical
Unit, for tlle skill and care witlh which hie hlas prepared
the diagrams that i-llustrate tllis paper.
Brigade - Surgeon Lieutenanit - Colonel Andrew Barry,
I.M.S., of St. Andrews, Fife, left )ersonal estate valuie(d at
£23,066.
THE report of the Surgeot-General of the United States
Navy for the fiscal year 1915 shows that the death-ra'te
was only 4.18 per 1,000 per annum. Three years ago there,
were 222 cases of typhoid fever with 15 deaths; the
present report shows 13 cases with no death. This im-
provemtent is said to be due almnost entirely to prophy-
lactic inoculation. The rate for 'venereal diseases wvas
.higher than that for 1913, but lower than those for 1909-12.
The rates for tuberculosis showed improvemen