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Primary Surgery, Chapter 62 - Maxillofacial injuries

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  • 1. CHAPTER 62 Maxillofacial injuries62.1 The general method for maxillofacial FRACTURES OF THE MIDDLE injuries THIRD OF THE FACEA patient with a severe facial injury is a very distressingsight—so distressing that you may feel that you can do noth-ing for him. In fact, you can do much, and maxillofacial in- fractures ofjuries are no more difficult (or easy) than any others. They the nasalare usually the result of road accidents, and seat belts pre- complexvent most of them. fractures of the Not suprisingly, the parts of the face which stick out are zygomaticthose which are most often injured—a patient’s nose, his zy- complexgoma, or his mandible. Fortunately, their injuries are usu-ally not too difficult to treat. Much greater force has to beapplied to fracture his maxilla, with the result that maxil-lary injuries are less common, but much more difficult. Al-though we describe each injury separately here, a patient is 3 Le Fort fractureslikely to have several of them, and other injuries also, espe- 2cially injuries to his head and eyes. 1 alveolus Fractures of the middle third of the face are so complexthat we shall not attempt to classify them except to say thatthe usual classification is that of Le Fort, who divided theminto Types One, Two, and Three, as shown in Fig. 62-1. Ina Type One fracture the alveolus, or tooth bearing part ofthe patient’s upper jaw, breaks off, and may drop onto hislower teeth. In Types Two and Three the fracture lines are In a Le Fort type I fracture the alveolus becomes loose and dropshigher up in his maxilla. These fracture types may be com- onto the lower teethbined, and may occur on one or both sides. The radiology, Fig. 62.1: FRACTURES OF THE MIDDLE THIRD OF THE FACE. In areduction, and fixation of the more difficult Le Fort fractures Type One fracture the alveolus, or tooth bearing part of the patient’s upperis beyond a district hospital. But prompt treatment, partic- jaw, breaks off, and may drop onto his lower teeth. In Types Two and Threeularly in securing a patient’s airway, may save his life, after the bones of the middle of the patient’s face slide downwards, as shown inwhich you have several days in which to refer him for ex- the next figure. These fracture types may be combined and may occur onpert reduction and fixation. Failure to reduce one of these one or both sides.fractures can cause severe deformities, which include a jawwhich does not close, ’dish face’, and diplopia. If you can- (2) It pushes his upper molars down onto his lower onesnot refer a patient, we describe some of the easier methods so that they gag (prevent his jaw closing properly). (3) Ityou can use. pushes his soft palate down onto his tongue and prevents him breathing through this mouth. At the same time, his WHAT OTHER INJURIES DOES THE PATIENT HAVE? fracture bleeds severely, and his nose is obstructed by blood clot. The result is that he may suffocate, so the immediate life saving procedure is to hook two of your fingers round the back of is hard palate, and pull his maxilla back up the inclined plane of his The critical displacement in Le Fort fractures of Types skull. This will allow him to breathe. His breathing can alsoTwo and Three is the downward movement of the bones of be obstructed by bilateral fractures of his lower jaw whichthe middle of the patient’s face, as shown in Fig. 62-2. The allow his tongue to fall back against his pharynx.strong front of his cranium forms an inclined plane, down Fractures of the middle third of a patient’s face have sev-which his facial skeleton slides. (1) This lengthens his face. eral other unfortunate features: (1) They are always multi- 1
  • 2. 62 Maxillofacial injuriesDOWNWARD (70.9). Occasionally an arch bar is useful. If you can get the A help of a dentist, always do so.DISPLACEMENTOF THE MAXILLA •ARCH BAR, stainless steel, five only. Sometimes, the most con- venient way to fix the fragments of a patient’s upper or lower jaw is to bend a metal bar, to shape it, and to wire it to his teeth. If you don’t have a proper arch bar, you can use any tough piece of respiratory obstruction stainless steel wire, or even some paper clips twisted together. treated with a nasopharyngeal airway A SWOLLEN FACE CAN CONCEAL A MAJOR INJURY B C D THE GENERAL METHOD FOR A MAXILLOFACIAL INJURY This extends Section 51.3 on the care of a severely injured patient. Injuries to his lower jaw are described i n Section 62.7. the front of the maxilla respiration skull forms on pushed obstructed, soft inclined plane downwards palate pushed IMMEDIATE TREATMENT down onto tongue CAN THE PATIENT BREATHE? If his breathing is difficult, look into his mouth to see if: (1) his airway has been ob-Fig. 62.2: DOWNWARD DISPLACEMENT OF THE MAXILLA. A, structed by blood and vomit, (2) his soft palate has beenif the patient’s respiration is obstructed, push a nasopharyngeal airwaydown one or both sides of his nose. B, C, and D, show how the front of his driven down onto his tongue by displaced Le Fort fractures,skull forms an inclined plane down which his maxilla can be pushed. After or if, (3) his tongue has fallen backwards after a mandibularKilley, with kind permission. fracture? If his soft palate has been driven onto his tongue, hook your fingers round the back of his hard palate, andple, sometimes with 50 or more fragments. (2) Several of pull the bones of the middle of his face gently upwards andhis cranial nerves may be injured, especially his infraorbital forwards, so as to restore his airway and perhaps the circu-and superior dental nerves. (3) His ethmoid may be frac- lation to his eyes. Reduction may not be easy, and you maytured and his dura torn, so that CSF leaks from his nose. need considerable force. If the fracture is impacted and you(4) His orbit may be fractured (Fig. 62-3), sometimes with fail to reduce it, he may need a tracheostomy, as describedthe displacement of its contents into his maxillary sinuses below.(the orbital blow-out syndrome). (5) The circulation to his If necessary, grip his maxillary alveolus with the specialeye may be obstructed and make him blind if the obstruc- forceps (Rowe’s) for this purpose, or with suitable strongtion is not relieved within minutes of the accident (the oph-thalmic canal syndrome). (6) His maxillary sinuses may fillwith blood. (7) His nasolachrymal ducts may be injured and THE ORBITALcause a flow of tears. A BLOW−OUT When you treat such a patient aim to: (1) Restore his air- SYNDROMEway. (2) Control bleeding. (3) Make his teeth bite normally.You should be able to do this with most fractures of hismandible, and some fractures of his maxilla. If either hismaxilla or his mandible is intact, you can use one of them to Bsplint the other. If you can make his bite normal, reduction willbe perfect. (4) Prevent some deformities by reducing fractures orbitalof his nose and zygoma. floor antrum loss of upward If you can refer a patient, do so early because the longer movementyou wait, the more difficult reduction will become. If youcannot refer him, you can certainly save his life, but he mayhave to live with his deformities. Soon after the injury hisface will look distressingly swollen, so do your best to reas-sure him and his family. The face has a good blood supply enophtalmusand will heal well, so that they can expect him to improveremarkably. But it can also swell quickly and hide under- depressionlying deformities, so examine him with care when you first Fig. 62.3: THE ORBITAL BLOW-OUT SYNDROME. A, a blow to thesee him. patient’s orbit has broken its floor, so that its contents have prolapsed into The methods we describe assume you don’t have a den- his antrum. B, unless you refer him to have it repaired, he may have per-tal laboratory, and so cannot make cap splints, etc. You manent enophthalmos, diplopia and loss of upward eye movement. Fromwill however need a drill and some soft stainless steel wire Rutherford, Nelson, Weston and Wilson with kind permission.2
  • 3. 62.1 The general method for maxillofacial injuriesA MAXILLOFACIAL TWO COMPLICATIONSINJURY Cerebrospinal A rhinorrhoea Retrobulbar haemorrhage A B C Fig. 62.5: TWO COMPLICATIONS OF A HEAD OR MAXILLOFA- CIAL INJURY A, fractures of a patient’s ethmoid may make his CSF leak. B B, a fracture of the base of his skull may cause severe proptosis and com- press his optic nerves. Drain the blood by making an incision near his outer canthus. After Duke Elder. is troublesome oozing, apply an adrenaline soaked packFig. 62.4: A SEVERE MAXILLOFACIAL INJURY A, note that a con- firmly to the bleeding surface. A postnasal pack (Chapterscious patient is likely to be more comfortable sitting forward. B, and C, if 24) will usually stop bleeding. If necessary, use large tempo-he has much tissue loss, transport him face down like this. After Killey with rary haemostatic sutures (3.1), but take care not to stranglekind permission. the tissues. If a wound is deep, be prepared to pack it. Occasionally,sharp toothed forceps, and rock it to disimpact the frag- you may have to tie a patient’s external carotid artery (3.5).ments. SHOCK is unusual. If a patient is shocked, suspect that If his tongue or lower jaw has fallen backwards, put he also has an abdominal or a thoracic injury.some sutures or a towel clip through it, and gently pull itforwards. Lying him on his side will also help. When you THE HISTORY AND EXAMINATION OF Atransport him, lie him on his side. MAXILLOFACIAL INJURY If he has a severe jaw injury with much tissue loss,transport him lying on his front with his head over the end The patient is probably unable to talk, so enquire from ob-of the stretcher and his forehead supported by bandages servers if he lost consciousness and so might have a headbetween its handles, as in Fig. 62-4. injury (63.1). If he feels more comfortable sitting up, let him do so. Gently wash his face with warm water to remove cakedHis airway may improve remarkably when he does this. blood. Look at it carefully for asymmetry. Compare one side Suck out his mouth, remove blood clots, debris, loose with the other throughout the examination. Is his nose or histeeth, vomit, and foreign bodies. face flattened? If you suspect a fracture of his zygoma, look A Guedel airway does not help, so don’t waste time trying at it from above and below and use the two pencil test in Fig.to insert one. Tracheal intubation is usually impractical. 62-12. If his nose is severely injured and bleeding, suck it BRUISING This is a useful guide to underlying injuries.clear and insert a nasopharyngeal tube, or any similar thick Zygomatic fractures There is always bruising round therubber tube, down one side. Put a safety pin through it to patient’s orbits, which develops rapidly as a uniform continu-stop it slipping, as in A, Fig. 62-2. ous sheet. It is limited peripherally by the attachments of his CAUTION! A nasopharyngeal tube does not always en- orbicularis muscle, and extends subconjunctivally towardssure a clear airway because it may kink or block against his eye from the lateral side. Ask him to look inwards Youthe posterior pharyngeal wall, so watch it carefully and twist will see bruising extending back into his orbit without a pos-and adjust it as necessary. Keep it sucked out by passing terior limit.a smaller tube down it, attached to a sucker. Use the same Look inside his mouth and examine his upper buccal sul-equipment to suck out the patient’s mouth, and keep it be- cus for bruising, tenderness, and crepitation over his zygo-side his bed. matic buttresses. Tracheostomy. You may need to do a tracheostomy Nasal fractures There is bruising round his orbits which(52.2) if: (1) You cannot disimpact and reduce the fracture is most severe medially.of the middle third of a patient’s face. (2) You cannot control Black eye This is the main differential diagnosis. Or-severe posterior bleeding. (3) He has oedema of his glot- bita bruising is most severe medially. It is subconjunctival,tis, particularly following a neck injury. (4) He has a severe patchy, and bright red.injury with much tissue loss. Tracheostomy will be difficult. EYES Has either of the patient’s eyes sunk inwards orUse ketamine, local anaesthesia and a cuffed tube. downwards? Are they level? Displacement may indicate CAUTION! If his breathing is in danger and you have to herniation of the contents of his orbit through its floor into hisrefer him, he will be safer with a tracheostomy than with a maxillary sinus, or a fracture at the fronto–zygomatic suturesuture through his tongue to pull it forward, which is the other line.alternative. Separate his eyelids, and test the sight of each of his eyes STOP BLEEDING Tie any large bleeding vessels. If there separately. If an eye is blind, its optic nerve may be injured. 3
  • 4. 62 Maxillofacial injuriesAsk him to follow your finger as you test for diplopia. This orbits showing they have been fractured.may be due to: (1) displacement of his orbit, (2) displace-ment of his globe, (3) a 6th nerve palsy, or (4) oedema. If hiseye is unable to look upwards, its inferior rectus is trapped, WOUND TOILET AND CLOSURE AFTER Aand his orbital floor is probably fractured. Note the size of MAXILLOFACIAL INJURYhis pupils and their reaction to light. This must be thorough, especially if sand or tar are ingrained If he has massive proptosis, he has a retrobulbar haem- In the patient’s wounds. If you don’t remove them, severeorrhage which may be compressing his optic nerve. Make fibrosis and disfigurement will follow. You will find a sterilea small incision at his outer canthus, take a haemostat and toothbrush useful.push this into the incision (B, Fig. 62-5); blood will squirt out. Handle his tissues gently with skin hooks and fine for-If you don’t do this, his eye will become blind. ceps. Remove soiled tags of deeper tissues and mucosa FRACTURES OF THE FACE AND SKULL Carefully feel with scissors. Trim only 1 or 2 mm of skin edge to provideall over the patient’s head and face for tenderness, step de- non–bevelled uncontaminated skin edges which you can ap-formities, irregularity, or crepitus. Feel his zygomatic bones, proximate accurately. Use a sharp No. 15 blade and oph-the edges of his orbits, his palate, and the bones of his nose. thalmic scissors. Close his mucosa with 310 silk, or failingIn a Le Fort Type Two or Three fracture you will feel many this with fine chromic catgut. Close his skin by primary su-small bony fragments under the skin in his ethmoid region. ture after you have fixed any fractures. If necessary, you can Hold the root of his nose between your finger and thumb. undermine the skin of his face for 2 to 3 cm to assist closure.At the same time put two fingers from your other hand into If part of the patient’s cheek Is missing, refer him im-his mouth. If you can move his facial skeleton on his skull, mediately for primary reconstruction. If this is impractical,he has a Le Fort fracture. You may feel it move more easily stitch his buccal mucosa to his skin (61-4). If necessary, doif you hold his upper gum between your thumb and index the same with his nose.finger. If there are loose bone fragments, conserve them un- Can he open and shut his mouth, bite normally, move his less they are grossly soiled. You can sterilize detached frag-jaw from side to side and protrude it? Do his teeth meet ments in boiling water and replace them as chip grafts.normally? If his bite is abnormal, one or both of his jaws CAUTION! (1) Don’t close his skin under tension. (2)have been fractured. Failure to move his jaw normally may Don’t leave bone bare—try to cover all bony surfaces.indicate a displaced fracture of his zygoma or his mandible. Examine the mucosa of both his jaws for bruising, tender-ness, irregularity, and crepitus. REDUCING FRACTURES AFTER A MAXILLOFACIAL NERVE INJURIES Test for anaesthesia of his cheeks (in- INJURYfraorbital nerves) and upper gums (superior dental nerves). Reduce and, where necessary, fix any fractures of the pa- TOOTH INJURIES Feel his teeth and try to rock them. tient’s nose (62.4), zygoma (62.5), and mandible (62.7).Individual teeth may move abnormally, so may several adja- These are not urgent operations, so resuscitate him first.cent teeth. Mobile teeth can be caused by: (1) A fracture. For anaesthesia, see A 6.4, and A 16.10. You can do most(2) Exposure of their roots. (3) Periodontal disease. operations on an injured jaw using pterygopalatine blocks, Inspect his teeth with a mirror and probe. Tap them; if bilaterally if necessary.they give a cracked cup’ sound, the bone above them maybe fractured. If a piece of tooth is missing, X-ray the patient’schest in case he has inhaled it. EXAMINING NOSE INJURIES Epistaxis is usually unilateral or absent A ZYGOMATIC A Bin zygomatic fractures, and bilateral in nasal ones. Examine INJURYthe patient’s nasal septum with a speculum. This may be antrumdisplaced in a nasal fracture. However, it is often asymmet-rical in otherwise normal people. If he has a haematoma of if the body of histhe septum, it needs evacuating, goto 61.4. zygoma is depressed LEAKING CSF may be anterior or posterior, and is usually one finger will be lower feel for than the otherdiagnosed after a few days when bleeding and oedema have C D tenderness Esubsided. The patient may complain of a salty taste in hismouth. If you are uncertain if a discharge is CSF or not,test it as in Section 63.12. CSF may leak in severe naso– feel insideethmoidal ractures and in some Le Fort fractures. his mouth OTHER INJURIES Look for these (51.3), and especiallyfor a head injury (63.1), or an injury to the patient’s cervicalspine (64.3). These may be more serious than those of his Fig. 62.6: EXAMINING A ZYGOMATIC INJURY A, the zygoma formsface. A maxillofacial injury does not usually cause shock, the prominence of the check, and also the floor and lateral wall of the orbit.so if he is shocked, suspect some other injury, especially an The maxillary antrum extends into it. B, if a fragment of the zygoma isabdominal one, which may take priority. displaced downwards, the patient’s lateral canthus will also be displaced X–RAYS are difficult to interpret, and involve turning the downwards, and his palpebral fissure will be oblique. C, press gently. If the body of his zygoma is depressed, one finger will be lower than the other.patient into a position which may obstruct his airway. Ask D, press gently on the lower border of his orbit, you may elicit tendernessfor: (1) An AP view of his mandible. (2) A Waters view of and feel a fracture between his zygoma and his maxilla. E, feel inside hishis skull in which you maybe able to recognise: (a) filling of mouth for a fracture in the lateral wall of his maxillary antrum. See alsohis maxillary antra, and (b) irregularities in the outlines of his Fig. 62-12. After Watson Jones with kind permission.4
  • 5. 62.2 Injuries to the teeth an alveolus CAUTION! Always protect a patient’s eyes when you op- 62.2 Injuries to the teeth an alveoluserate on his face. If he has a Lie Fort fracture, or an orbital floor fracture, The front of a patient’s upper jaw is most at risk. In less se-refer him. If you cannot refer him, the next section (62.2) vere injuries only his teeth are damaged, in more severe onesdescribes some methods you may be able to use. his alveolus may be fractured. Although injured teeth do not threaten life, they are acutely painful, especially when the pulp is hanging out. When a tooth is hit: (1) its crownNURSING A MAXILLOFACIAL INJURY may fracture, (2) its root may fracture, (3) the whole toothIf the patient is conscious, sit him well forward, so that his may subluxate, (4) it may be impacted into the surroundingtongue falls forward, and blood and saliva can dribble out of tissue, or, (5) it may be inhaled, and be followed by a lunghis mouth. This will make him comfortable and also help him abscess.to breathe. If he is unconscious, turn him onto his side into the re- INJURIES TO THE TEETH AND ALVEOLUScovery position (51-2), so that blood and saliva can run outof his nose and mouth. If other injuries prevent this, put a If the patient’s oral mucosa is torn, suture it with fine 4/0pillow under one shoulder, and turn his head to the other waxed silk or chromic catgut.side. If the crown of a patient’s tooth is missing, its exposed FOOD AND FLUIDS If the patient is to be operated on, pulp will be visible as a pink spot on the root surface. It willwithhold these. Otherwise feed him through a tube. be acutely painful, so touch it with phenol on a small piece of CLEANING AND DISINFECTION is critically important for cotton wool. This will kill and anaesthetize the nerve. Takethe healing of all wounds inside a patient’s mouth. Ask him a chest X–ray in case he has inhaled the missing fragment.to rinse out his mouth after eating, using :(1) a rinse contain- It will have to be removed by bronchoscopy.ing 10 ml of 0.5% chlorhexidine, or (2) 2% salt solution, or If a tooth is only mildly subluxed, leave it in place; it willfailing either of these, (3) plain water. As soon as possible, probably tighten up and live. Meanwhile splint it with a pieceencourage him to clean his teeth regularly with a toothbrush of lead foil or the top of a milk bottle moulded to the toothor a clean chewing stick. and gum. Coat his lips liberally with vaseline to stop them sticking If a tooth is so loose that you can lift it up and downtogether and interfering with his respiration. in its socket, remove it. A dentist may be able to splint it and re–implant it, if he sees it soon enough, so don’t delay.DRUGS FOR A MAXILLOFACIAL INJURY If there is an opening between a patient’s antrum and his mouth, try to close it. If his antrum is already infected,Give the patient amoxycillin, ampicillin, or fortified procaine leave it open and irrigate it daily. Don’t pack it.penicillin for one week. Start immediately (2.7). This usually COMMINUTED FRACTURES OF THE ALVEOLUS If theprevents bone infection, and is important if a fracture opens bony fragment with its teeth is still attached to periosteum,into his mouth. leave it, and splint the patient’s teeth as best as you can If his CSF is leaking, give him 1 g of sulphadimidine 6 with an arch bar. If the fragment of alveolus is completelyhourly until 48 hours after it has stopped. Most leaks stop detached from the periosteum, dissect it out and remove it.spontaneously, except in severely comminuted fractures. GAPS IN THE MAXILLARY SINUS Close these temporar- CAUTION! Don’t give him powerful analgesics, such as ily by packing them with gauze impregnated with bismuth,morphine, which will depress his cough reflex. If he is rest- iodoform, and paraffin paste (BIPP), or with vaseline gauze.less, give him paradelyde or diazepam. As soon as the patient’s general condition is stabilized, close Don’t forget tetanus prophylaxis (54.11). the gap with a flap of mucosa from his adjacent cheek. Su- CHARTS Start a head injury chart (63-4) and a fluid bal- ture it carefully, preferably with 3/0 black waxed silk sutures.ance chart (A 15-5). Tell him not to blow his nose and to sneeze with his mouth open.FURTHER MANAGEMENT OF A MAXILLOFACIAL MISSING DENTURES A piece of denture can also be in-INJURY haled. It is unlikely to be radio–opaque, so a normal chest X–ray does not exclude inhalation.If possible, refer all more serious injuries. Read on for in-juries to a patient’s teeth and alveoli (62.2), simpler methodsfor maxillary fractures (62.3), fractures of the patient’s nose 62.3 Simpler methods for maxillary fractures(62.4), fractures of his zygomatic complex (62.5), dislocationof his jaw (62.6), the general method for a dislocated lower There are few easy methods for Le Fort fractures. If the pa-jaw (62.7), fractured condyles (62.8), fractures of the as- tient is lucky enough to have an intact mandible, you cancending ramus of his mandible (62.9), fractures of the angle wire his broken maxilla to it. Packing his maxillary sinusesand body of his mandible (62.10), difficulties with mandibular and repairing his orbital floor are beyond a district hospital.fractures (62.11), and fixing mandibular fractures with acrylicresin (62.8). Le Fort Type One fractures with an intact mandible Alveolar fractures are quite common, so to be able to doTRANSPORT MAXILLOFACIAL INJURIES PRONE OR LYING anything for them is useful. Although they are much eas- ON THEIR SIDES ier to fix if the patient has an intact mandible, you may be able to fix a mandibular fracture with an arch bar, and then proceed as if his mandible were intact. 5
  • 6. 62 Maxillofacial injuries METHODS FOR If he has a Le Fort Type One fracture on one side only, half A his alveolus hangs loose on that side, as in A, Fig. 62-8. If LE FORT interdental his mandible is intact you can wire it to the intact half of his FRACTURES wiring on the other side alveolus, so that it holds the fractured half reduced. If his alveolus has fractured on both sides, and he has an intact mandible, you can wire his zygomatic arches on both D sides to his mandible, as in B, Fig. 62-8. Type Two Fractures In some Type Two fractures the zy- gomatic arches are intact, but the bones of the centre of the patient’s face are displaced. You may be able to drill a Kirschner wire through one zygomatic arch, through the unilateral displaced central fragment of the face, and then out through alveolar the other arch. No! gross malocclusion fracture Le Fort I WIRING THE ZYGOMATIC ARCH TO THE MANDIBLE B C INDICATIONS Maxillary fractures with an intact mandible. wire round zygomatic Kirschner ANAESTHESIA Premeditate the patient well and use in- arches wire filtration anaesthesia of his gums (A 6.3). Fix wire eyelets to his teeth on both sides of his lowerjaw as in Section 62.10. Protect his eyes as in Section 62.4. Push a blunt aspi- ration needle or large lumbar puncture needle through his skin just above his zygomatic arch and posterior to his outer canthus. Push the needle downwards behind his zygomatic arch into his superior buccal sulcus, as in E, Fig. 62-8. eyelet wires Thread wire through the needle and then remove the nee- dle, leaving the wire in his tissues (F). bilateral alveolar central part of Now pass the needle up from his buccal sulcus, superficial fractures, Le Fort I face loose, Le Fort II to his zygomatic arch, under his skin, to come out of the same hole in his skin as the wire (G). Pass the other end of wire through the needle so that it E F G emerges in his buccal sulcus. Remove the needle. You will now have a loop of wire passing round his zygomatic arch with both ends emerging in his buccal sulcus. Repeat the process on the other side, and then join the wire loops to the eyelets that you have previously fixed to his mandible. 62.4 Fractures of the nose A patient’s injured nose is displaced, swollen and bleeding. Sometimes the swelling hides his displaced bones under- neath, so always suspect a fracture after any blow on the nose. He may have blood in his orbits and under the medial halves of both his conjunctivae. A force applied to the side of the nose pushes it sideways. A force applied from in front squashes it and splays it out- wards. If you don’t treat these injuries, they produce the de- formities shown in Fig. 62-9. If the force is severe enough,Fig. 62.7: SIMPLER METHODS FOR LE FORT FRACTURES. A, in- it can: (1) Fracture the frontal processes of a patient’s maxil-terdental wiring holding a unilateral fracture in place. B, wire round lae. (2) Displace his nasal cartilages. (3) Dislodge his septalthe patient’s zygomatic arches holding a bilateral fracture in place. C, a cartilage from its groove in his vomer. (4) Comminute hisKirschner wire holding the central part of his face in place. D, this figure vomer. (5) Fracture his ethmoid bones so that CSF flowswas drawn from a cast, and shows what can happen if you fail to reduce asevere maxillary injury. Note the gross malocclusion. The patient’s jaws from his nose.will have to be refractured and reset. Aligning them would have beenmuch easier at the time of the injury. E, a lumbar puncture needle hasbeen passed medial to his zygomatic arch into his upper buccal sulcus, and TREATING A BROKEN NOSEwas passed down it. F, the needle has been withdrawn. G, the needle is be-ing passed lateral to the zygomatic arch. Kindly contributed by Susan Likimani See also Section 61.4.and Andrew Curnock. CONTROLLING BLEEDING If this is severe, pack the pa- tient’s nose with ribbon gauze soaked in saline. Treat him as soon as possible without waiting for the swelling to go down.6
  • 7. 62.4 Fractures of the noseUNREDUCED ELEVATING ANASAL FRACTURES FRACTURED NOSE depressed bridge of the nose A blow from in front A anaesthetise B the fracture elevate the deviation of the nose fracture and restore the A blow from the side shape of the nose curved artery forceps Fig. 62.9: ELEV ATING A FRACTURE OF THE NOSE. A, inflitrating the site of the fracture. B, raising the depressed bones with curved arteryFig. 62.8: UNREDUCED FRACTURES OF THE NOSE. If you don’t forceps. Always suspect a fracture after any blow on the nose. Swelling ofreduce a patient’s broken nose, these are some of the possible results. After the soft tissues can easily hide it. Kindly contributed by Peter Bewes.Killey, permission requested. A plaster cast Make eight thicknesses of plaster bandage EQUIPMENT If possible, use Walsham’s forceps to re- into a T–shape. Wet this and put it on the patient’s nose andduce his nasal bones, and Ash’s forceps to straighten his forehead. If any plaster overlaps the lower end of his nose,nasal septum. If you don’t have them, you can use any stout turn it up like a brim. As it sets, mould it to his forehead andclamp, but don’t close it tight. Walsham’s forceps don’t quite the sides of his nose. Strengthen the plaster over the bridgemeet, and therefore don’t crush tissue. of his nose with two more layers of plaster bandage. ANAESTHESIA (1) Pterygopalatine block (A 6.4). (2) Remove the vaseline gauze squares from his eyes, andGive the patient a general anaesthetic, and pass a trachealtube (A 13.2). (3) Use local infiltration anaesthesia. PROTECT THE PATIENT’S EYES Put squares of vaseline MAKING Agauze over both his eyes to prevent plaster getting into them. PLASTER REDUCTION Clean the patient’s face with cetrimide to re- NASAL SPLINTmove grease. Examine his nose carefully with your fingers. A Cover one blade of Walsham’s forceps, or some other suit- straighteningable instrument, with rubber tube. Pass it into his nose and the noselever the fragments of his bridge into place. Then do thesame on the other side. If necessary, mould his comminuted lachrymal bones, and T−shaped plaster splintthe medial walls of his orbits, so as to reconstitute the bridgeof his nose. B CAUTION! (1) Don’t forget to protect his eyes. (2) Try hard packs to prevent Walsham’s plaster entering forcepsto restore the full height of the bridge of his nose. the nose When you have done this, pass one blade of Asch’s septal Cforceps, or any other suitable instrument, down each sideof the patient’s septum and straighten it, so that it lies inthe midline. If necessary, grasp his septal cartilage, bring itforward, and replace it in its groove in his vomer. dry Pass an instrument down each side of the nose to make plastersure he has a clear nasal airway. Pack both his nostril’s with bandage1 cm selvedgeless gauze soaked in liquid paraffin. SPLINTING If the fracture is mild, no splint is needed. If Fig. 62.10: A PLASTER NASAL SPLINT. A, reducing the fracture withthe fracture is severe, splint it, either with a plaster cast, or Walsham’s forceps. B, the splint in place. C, dry plaster bandage ready forwith lead splints. preparing the splint. Kindly contributed by Peter Bewes. 7
  • 8. 62 Maxillofacial injuriesthen wrap a crepe bandage round his head to hold the cast. jury to his infra–orbital nerve makes his cheek numb, andOr, hold it in place with adhesive strapping. It will hold his displacement of the lower part of his orbit pushes his eyenose in place by suction. downwards, and restricts its movements. Herniation of the CAUTION! Don’t fix the splint to a plaster headcap, be- fat in his orbit into his maxillary sinus may also make hiscause if this displaces, it will displace his broken nose. eye sink inwards and downwards, and cause diplopia. This When oedema has subsided in a few days, fit a fresh cast. can also be caused by injuries of his 6th nerve, or his ocularLeave this for 2 weeks. muscles or their attachments. It can be temporary or per- manent. If it is due to a fracture of his zygomatic complex, reducing this may correct it.A lead splint If the fracture is too severely comminuted tobe held in a plaster splint, hold it with two lead plates, oneon each side of the patient’s nose. You can use two or three Fractures of the zygomatic arch Sometimes, only thelayers of the lead backing from some infra–oral X–ray films. arch of a patient’s zygoma is fractured. There is a depres-Pass a mattress suture of 0.35 mm soft stainless steel wire sion over it, and the movement of the coronoid process ofthrough his nose with a straight needle. his mandible is restricted. Although the depression maybe obvious at the time of the injury, it may rapidly fill with oedema and become invisible. If his mouth was open when62.5 Fractures of the zygomatic complex he was injured, he may be unable to close his jaw. Don’t try to elevate the fragment, unless he has difficulty moving hisA blow to the side of a patient’s face drives his zygoma in- jaw.wards, usually on one side only. The zygomatic bones are soclosely united to the frontal and temporal bones, that, when Reducing fractures of the zygomatic complex Frag-they fracture, the neighbouring parts of these other bones ments of the zygomatic arch are held by the zygomatic fas-usually do so too. The zygomatic complex therefore usually cia, and although they may displace inwards, they don’tfractures as a whole. The displaced zygomatic fragment can move in other directions. The patient’s temporalis fasciarotate clockwise, or anticlockwise, and its orbital rim can be is attached to the superior border of his zygomatic arch,inverted or everted. The floor of the orbit is always partly whereas his temporalis muscle is attached to his coronoidcomminuted. process. This enables you to pass an elevator between the If you see a patient early enough, you may see that the fascia and the muscle, and lever his zygomatic arch out-side of his face is flattened. Oedema fills out this flattening wards into place. Try to operate within the first 48 hours,within three hours, and it does not return for a week, after when the replaced fragment is more likely to be stable andthe oedema has subsided. If you are in doubt, there is a use- less likely to need wiring. After two weeks, the ends of theful test for flattening of the zygoma. Put two pencils on ei- fragments will have softened and rounded, and you willther side of his face. They should lie parallel to one another. probably need to wire them, after 4 weeks they will haveIf the lower end of a pencil is tilted inwards, the patient’s united so that you cannot move them. After this length ofzygoma is flattened on that side, as in Fig. 62-12. The ob- time they will probably need open refracture, open reduc-viousness of this flattening depends greatly on whether he tion, and wiring.has a thin bony, face which accentuates the displacement, or The methods below do not include packing the maxillarya fat one, which hides it. sinus, and repairing the orbital floor. If the contents of a When a patient’s zygoma is injured, his maxillary sinus patient’s orbit have prolapsed into his maxillary sinus, andfills with blood, so that his nose bleeds from that side. In- you cannot refer him, he will have to live with his enoph- thalmos and wear an eye patch.TESTING FOR A FRACTUREOF THE ZYGOMA ELEVATING A FRACTURED ZYGOMA INDICATIONS (1) Inability of the patient to open and close his jaw. (2) Diplopia. If you are inexperienced, and he can deviation move his jaw normally and can see straight, disregard any of the deformity and don’t operate. use two ruler rulers on the The method described here is for the zygomatic arch. By fractured a slight change in the position of the lever, you can also use side it for fractures of the body of his zygoma and the adjacent part of his maxilla. EQUIPMENT A general set with a Bristowe’s elevator, or a McDonald’s elevator, or a long secrewdriver. ANAESTHESIA Give the patient a general anaesthetic and intubate him (13.2). REDUCTION Be sure to protect the patient’s eyes. Make a 2 cm antero–posterior incision in his temporalfossa, just above his hairline, as in A, Fig. 62-13. Reflect his skin. Underneath the skin and the superficial fascia you will see his auricularis superior muscle. Cut inFig. 62.11: EXAMINING FOR A FRACTURE OF THE ZYGOMA. See the line of Its fibres (B). If his hairline is low, and the inci-also Figure 62-6. Kindly contributed by Peter Bewes—it is a good likeness of him!. sion is lower, you may meet the fibres of auricularis anterior.8
  • 9. 62.6 Dislocation of the jawELEVATING A the fracture line by blunt dissection through an incision inDEPRESSED ZYGOMA one of the wrinkles at the corner of the patient’s eye. Take care to avoid the branches of his facial nerve supplying his cut auricularis superior orbicularis muscle. Drill small holes in the bone and fix the small in the line of its fibres incision fragments in place with soft stainless steel wire. WIRING A ZYGOMATIC–MAXILLARY FRACTURE Make A B a 1 cm incision just below the lower rim of the patient’s orbit. Drill small holes and wire the fragments together. D ALTERNATIVELY, in some fractures you may be able to gauze grasp the fragments through his skin with tenaculum for- roll as ceps.avoid fulcrumhis CLOSING THE WOUND Close his deep temporal fasciasuperficial cut the temporal with a few monofilament sutures. Put a firm pressure padtemporalartery fascia C over the skin incision. 62.6 Dislocation of the jaw elevator passing When a patient dislocates his jaw, his mandibular condyles between the slip forward in their sockets over the articular eminences of temporalis muscle his temporomandibular joints. This can happen when he and the temporalis fascia laughs or yawns, or is hit in the face with his mouth open. E The mouth of a patient with a dislocated jaw remains per- manently half open in an anterior open bite. Swallowing F is difficult, so that saliva dribbles from the corners of his lips. When you examine him, you find a small depression over his temporomandibular joints. If his mandible dislo- cates one side only, it deviates away from the midline. X THERESA was cultivating her fields in Zaire when she yawned and dislocated her jaw. She had been told that patients had to pay at the Catholic hospital, and as she had no money, she had to wait some weeks to sell some produce before she could go there. The most surgeons make the if the body of the zygoma is doctors there failed, because her dislocation was no longer recent, incision more anteriorly fractured, pass the elevator so she waited a few more weeks, sold some more produce, and tried forwards the Protestants. Her dislocation was now even older, and they tooFig. 62.12: ELEV ATING A DEPRESSED FRACTURE OF THE failed, so she now walks about with her mouth permanently open.ZYGOMATIC-MAXILLARY COMPLEX. A, the initial incision avoid- LESSONS Dislocations of the jaw are much easier to reduce if theying the superficial temporal vessels. B, dividing the auricularis superior. are done early. The tragedy of this patient is that both hospitalsC, incising the temporalis fascia. D, passing an elevator. E, elevating the would have treated her for free, if she had come early and told themarch. F, elevating the body of the zygoma. Kindly contributed by John M Lore she could not pay.Jr.These run more horizontally, so separate them in a horizon- REPLACING A DISLOCATED JAWtal plane. Underneath them lies his tough deep temporalfascia. Cut this to expose his temporalis muscle (C). The RECENT DISLOCATIONS Most patients need no anaes-fascia may have two layers. If so, incise them both. thetic. Pass a Bristow’s elevator between his temporalis fascia, Sit the patient forward in a chair. Ask an assistant to standand the surface of his temporalis muscle. Push it down until behind him and hold his head. Put some gauze over hisits end lies between his zygomatic bone and his temporalis lower posterior teeth on each side. Press his premolar teethmuscle (D). It should slip easily between the bone and the downwards. At the same time press the underneath of hismuscle. chin upwards and backwards. Using a gauze roll as a fulcrum to protect the upper skin If he opens his mouth too wide again, the dislocation mayedge, gently lever his zygoma into a slightly overcorrected recur. So bandage his jaw to keep his mouth shut for 3 days.position (E). Allow him to open it just a little for eating. If the body of a patient’s zygoma is fractured, pass the OLD DISLOCATIONS Fix arch bars to each jaw (62.10).elevator forwards, and lever it into position (F). Cut an ordinary rubber eraser into two pieces, and put a If the fragment is stable, no wiring is necessary. piece between the patient’s posterior molars on each side to If the fragment is unstable, wire its junctions with his act as a fulcrum. Fix strong rubber bands between the archfrontal or maxillary bones, or with both of them, through sep- bars in front. During the following few days they will exertarate small incisions. steady traction and close his anterior open bite. If this fails, WIRING A ZYGOMATIC–FRONTAL FRACTURE Expose refer him. 9
  • 10. 62 Maxillofacial injuriesREDUCING A out of his mouth.DISLOCATED JAW Examine his buccal and lingual sulci. Bruising in his buc- cal sulcus does not necessarily indicate a fracture, but bruis- ing in his lingual sulcus almost certainly does. Palpate his mandible down the whole length of each sulcus carefully. If you suspect a fracture, can you make the fragments move relative to one another? Examine the patient’s ears for bleeding. Put both your little fingers into them and compare the movement of his condyles. If you cannot feel a condyle moving, suspect a fracture. BITE AND MOVEMENTS Examine the patient’s bite. If he can cooperate, ask him to carry out a full range of mandibu- lar movements, and note any pain and limitation of move- press his premolar ment. teeth downwards, Test for anaesthesia of his mental nerve. Is he anaesthetic at the same time below his lower lip to one side of the midline? press the underneath of his chin X–RAYS Take antero–posterior, and right and left lateral upwards and backwards oblique views to show his rami, condyles, and coronoid pro- cesses. SOFT TISSUE INJURIES Do a careful wound toilet in-Fig. 62.13: REPLACING A DISLOCATED JAW Most patients don’t side and outside his mouth. Remove any foreign bodies andneed an anaesthetic. If necessary, give a patient pethidine or diazepam. all loose teeth in the line of the fracture, together with their roots. If there is loss of soft tissue, stitch his mucous mem- brane to the skin around the defect as best you can.62.7 The general method for an injured lower ANTIBIOTICS If a patient has an open fracture, give him jaw an antibitoic, such as amoxycillin, ampicillin, or fortified pro- caine penicillin, daily for 5 days in the hope of preventingA patient is hit on his jaw. One or more fractures tear the bone infection.mucoperiosteum covering the body of his mandible. He BANDAGES are usually unnecessary. If a patient needsdribbles bloody saliva, and can neither speak, swallow, nor one, apply a simple suspensory barrel bandage, not a four–close his teeth normally. Moving his injured jaw may be so tail bandage.painful that he holds it in his hands. If you move it gently METHODS FOR PARTICULAR FRACTURES Apply thefor him, you may be able to feel crepitus. appropriate methods for fractured condyles (62.8), for frac- Mandibular fractures can be unilateral or bilateral. The tures of the ramus (62.9), and for fractures of the body ofweak parts of the bone and the common sites for fractures the mandible (62.10). The coronoid processes (C, Fig. 62-are: (1) the neck of the condyles (B in Fig. 62-15), (2) the 15) can also be fractured, but the diagnosis is difficult. Theangles of the mandible (E, and F), and (3) the premolar re-gion (G). Fractures of the angle and body of the mandibleare open, but not those of the rami, condyles, or coronoid PATTERNS OF MANDIBULAR FRACTUREprocesses. Often, the patient has other injuries too, and thecombination of a jaw injury and a head injury is common. bilateralBut, provided there is no gross comminution or tissue loss, A fractured B fracture with displacement fracture of condyleyou should be able to treat most of these fractures success- the ramus Cfully. The mandible remodels readily, even after a commin- fractureduted fracture, and left untreated, many fractures will heal coronoid processthemselves, but only with considerable disability. The purpose of the mandible is to bite, so decide whether or fracture of the D angle in a directionnot the patient has a normal bite. If he has not, think how best you unilateral fracture that does not cause NORMAL allowing displacementcan restore it. The methods described below are for single displacementfractures. You will have to adapt them for multiple ones.THE GENERAL METHOD FOR AN INJURED ELOWER JAW fracture of the angle allowing H displacement midline fractureThis extends what has already been said in Section 62.1, on with minimal displacementthe care of a severe maxillofacial injury. If possible, consulta dentist early. EXAMINATION Feel both the patient’s condyles with thetips of your fingers, and then continue feeling downwards Falong the borders of his mandible. Feel for tenderness, step muscle pull Gdefects, alterations in contour, and crepitus. Look inside his mouth with a good light. Gently swab away Fig. 62.14: PATTERNS OF MANDIBULAR FRACTURES. The princi-any clotted blood. Lift any loose pieces of tooth and alveolus ple of reducing these fractures is to make the patient’s bite normal.10
  • 11. 62.9 Fractures of the ascending ramus of the mandibletreatment is active movements, so disregard this fracture. DIFFICULTIES WITH FRACTURES OF THE MANDIBULAR CONDYLES62.8 Fractured mandibular condyles If the patient Is a CHILD, no treatment is needed ini- tially. But follow him up carefully, because the growth of hisThese are the most common mandibular fractures (B, Fig. mandible may be arrested.62-15). They are often undiagnosed, and are often bilateral. If a patient’s BITE DOES NOT IMPROVE, refer him to a dentist. If serious malunion occurs condylectomy may be necessary.Unilateral condylar fractures The patient has pain,swelling, and tenderness over his temporomandibular jointon the injured side. He cannot move his jaw normally. FRACTURES OF THE CONDYLES ARE OFTEN MISSEDMovement away from the injured side is particularly dif-ficult. When he tries to move his jaw, it deviates towards theside of the fracture. His bite may or may not be normal andhe occasionally bleeds from his ear. 62.9 Fractures of the ascending ramus of the mandibleBilateral fractures All movements are painful and lim- The ramus of the patient’s injured mandible is tender,ited. Sometimes the patient’s bite is normal, or he may have swollen, and bruised, both outside and inside his mouth (A,an anterior open bite. Often he has a midline fracture also. Fig. 62-15). The fracture does not open into his mouth and The mandibular condyles are difficult to X–ray, and need there is little displacement unless violence has been extreme,special views, so it is fortunate that X–rays are not essential. because the muscles attached to the ramus splint it so well.Management depends on whether or not the patient has an If there is no displacement, encourage him to move his jaw.anterior open bite. If you fail to correct this, his molar teeth If there is significant displacement, fix his mandible by in-may later have to be ground away, so that his incisors can terdental wiring as described below.meet. If he has no teeth, an anterior open bite is less impor-tant, because it can be corrected with dentures. 62.10 Fractures of the angle or body of the mandibleFRACTURES OF THE MANDIBULAR CONDYLESIf possible, refer the patient, because ankylosis and devi- The angle of the mandible is one of its weak points, and isation of his jaw may follow unsuccessful treatment. If you the next most common site for fractures after the condyles.cannot refer him, proceed as follows. The fragments may or may not be displaced, depending on the severity of the injury and the direction of the fracture line (E, or F, in Fig. 62-15). If the fragments are displaced,FRACTURES WITH A NORMAL BITE the anterior one is pulled downwards by the muscles at- tached to it, while the posterior one is pulled upwards byAll unilateral fractures have a normal bite (if there is no other the patient’s masseter (F). Sometimes there is a tooth on theassociated fracture) and so do some bilateral ones. posterior fragment. Encourage the patient to move his jaw. Deviation of his If the fragments are not displaced, as in A, Fig. 62-15, youmandible towards the injured side is usually due to muscle can bandage the patient’s jaws together, and need not wirespasm, and soon improves, so that his bite becomes normal. them, although it is good practice to do so.Observe him to make sure that it does so. If the fragments are displaced, you will have to reduce and CAUTION! If you decide to immobilize his jaw because of fix them. If they have enough teeth in them, you can usepain, don’t do so for more than 10 days, or he may later have the patient’s upper jaw as a splint and wire the teeth of bothso little movement that he will be unable to open his mouth his jaws together (interdental eyelet wiring or intermaxillarynormally. fixation, IMF), or you can use an arch bar. Fortunately, most patients are young and have enough teeth to let you do this. Interdental eyelet wiring (occasionally with an arch bar) isFRACTURES WITH AN ANTERIOR OPEN BITE thus all that is necessary in most cases. If you don’t have an arch bar, you can use Risdon wiring, as in Fig. 62-19, whichAll these patients have bilateral fractures, or fracture dislo- is as good if not better. Or you can make an improvised archcations. bar with paper clips or fencing wire. If you don’t have the If the fragments are not impacted, you may be able to right kind of stainless steel wire, you can use ordinary brasssplint them using interdental wiring. If the patient has few wire, but it is not so strong.teeth, you may need to use an arch bar. If a patient does not have suitable teeth for interdental wiring, If the fragments are impacted, splint his jaws so as to you can drill holes in the fragments and wire them togetherdistract the ramus in the condylar region. Take an ordinary (interosseous wiring). Or, you can combine interdental andrubber. Cut two pieces from it 6 mm thick, and put them interosseous wiring. For example, if the anterior fragmentbetween his molar teeth on both sides. Then use adhesive has enough teeth to wire it to the maxilla, but the posteriortape traction or interdental wiring to make his incisors meet, fragment has not, you may be able to wire it to the anterioras in treating an old dislocation (62.6). Maintain this splinting one. Interosseous wiring is never enough by itsef and is only anfor 5 weeks. adjunct to interdental wiring. 11
  • 12. 62 Maxillofacial injuriesFRACTURE OFTHE ANGLE OF CAREFUL REGULAR ORAL HYGIENE IS ESSENTIAL TO ATHE MANDIBLE PREVENT OSTEOMYELITIS interdental wiring has been completed. interosseous wiring is now necessary Anaesthesia is critical. If neither you nor your assistant is an anaesthetic expert, the patient is probably safest under local anaesthesia. The alternative is to give him a general B anaesthetic, pass a nasotracheal tube, and pack his throat. The dangerous moment comes when you remove the pack before you finally close his jaws. While you are doing this, blood and saliva can collect in his pharynx. You cannot suck this out through wired jaws. So, when you do finally pull the tube out, he may inhale the collected blod and saliva, perhaps fatally, or he may have a severe inhalation pneumo- nia. Another moment of danger occurs as he recovers from the anaesthetic, when he may try to cough or vomit through closed jaws, so that you have to open them urgently. Local anaesthesia also reduces this risk. You can use ketamine, but it is not ideal. MOST FRACTURES OF THE BODY OF THE MANDIBLE NEED FIXING FRACTURES OF THE BODY OF THE MANDIBLE FRACTURES WITHOUT DISPLACEMENT If the patient’s upper and lower teeth oppose one another, soFig. 62.15: A FRACTURE OF THE ANGLE OF THE MANDIBLE. A, that he bites normally, there is no displacement. Provided heshows the fracture after interdental wiring and before interosseous wiring. is cooperative, there is no need to wire his fracture, althoughB, shows it before wiring. This is the patient whose mandible is being it is better practice to do so.wired in Fig. 62-19. John Maina’s patient. If the patient is cooperative, bandage his mandible to his maxilla, so that his teeth are firmly together. Use a crepe bandage, adhesive strapping, or a plaster bandage round Interosseous wiring is the most practical way of fixing his chin, his face, and his forehead. If you use a crepe ban-those fractures in which there is no other way of control- dage, rewrap it every day to maintain tension.ling the posterior fragment. The inferior alveolar nerve CAUTION! A bandage can be detrimental if you apply it inruns through the centre of the mandible, so always wire the a displaced fracture.mandible through its edges. You may need to wire it any- If a patient is uncooperative, he may remove his ban-where along its length. Wiring is easiest on the front of a dage, so you had better wire his fracture.patient’s chin. There are two approaches: (1) You can wirethe lower border of his mandible from outside his mouth.(2) It is possible to wire the upper border from inside it, but FRACTURES WITH DISPLACEMENT BUT NO TISSUEthis is more difficult, so avoid it if you can. The patient is LOSSlikely to be elderly and will probably tolerate his malocclu- If the fracture lies within the tooth bearing area, you havesion. two choices. If a patient wears a denture, you may be able to use this (1) If the patient is cooperative, unlikely to take the wiresas a splint, You can wire a lower denture to his mandible by off, and has plenty of teeth, use interdental eyelet wiring.circumferential wiring, or you can suspend an upper den- (2) If he is uncooperative, if he has few teeth, or if there isture from his zygomatic arches by an adaptation of method gross displacement, use arch bars or Risdon wiring.B, in Fig. 62-8. If the fracture lies outside the tooth bearing area, use Fractures of the ramus are open, and are easily infected interosseous wiring combined with interdental wiring, or archby bacteria from the mouth. Osteomyelitis, sometimes with bars or Risdon wiring on the same criteria as (1) and (2)extensive fistulae, is thus an important complication, and above.may follow interosseous wiring. Fortunately, prophylactic If he has no teeth, refer him. If you cannot refer him, doantibiotics will usually prevent it. your best with interosseous wiring. If for any reason you cannot fix these fractures, remod- If you have no suitable wire, do your best with a headelling will occur in those which involve the angle with up- bandage, as in Fig. 62-17.ward and forward displacement of the posterior fragment, If possible, operate during the first 24 hours, but if oedemaand in most comminuted fractures. It will not occur in frac- is severe, you can wait up to a week to let it subside. If youtures near the genial tubercles. are in any doubt about the patient’s general condition, wait.12
  • 13. 62.10 Fractures of the angle or body of the mandibleFIXING THE CONTRAINDICATIONS If a patient is drunk and there isMANDIBLE A any danger of vomiting, don’t wire his teeth until his stomach is empty. ANAESTHESIA FOR EYELET WIRING OR ARCH BARS MAKING See above. There are several possibilities. (1) If displace- RUBBER BANDS ment is mild and he is cooperative, use local anaesthesia only. Premedicate him with pethidine and diazepam (A 5.2). Use pterygopalatine (A 6.4) and mandibular (A 6.3) blocks, B if necessary on both sides. Supplement these where re- quired, by infiltrating the mucosa round his teeth (A 6.3). Al- A WIRE EYELET A BANDAGE FOR AN ternatively, use infiltration anaesthesia only. If you are using UNDISPLACED FRACTURE local anaesthesia, sit him in a dental chair. (2) If his injuries are severe and you are an anaesthetist expert, induce him with ether or halothane (A 11.3), and intubate him through FIXING AN EYELET D his nose (A 13.4). (3) Ketamine can be used. 3 CAUTION! Pass a nasogastric tube and aspirate his stom- C ach before inducing him. WORKING WITH WIRE Use soft 0.35 mm stainless steel 4 2 wire, or any convenient soft wire. Stretch it before you use rubber band it, or it will become slack, but don’t over-stretch it, or it will 1 become hard and brittle. Making eyelets Cut the wire into 150 mm lengths, take hold of each end in a pair of artery forceps, and twist it round a 3 mm bar to make the eyelets shown in B, Fig. 62-17. INTERDENTAL EYELET WIRING Keep 20 of them ready in a box in the theatre. E Twisting wire inside the mouth Twist it by holding its ends in a stout pair of artery forceps. Pull the ends taught from time to time, and rotate them in your fingers, as in Fig. 62-18. You will need to make many twists and this is much the quickest way of making them. Precautions with wire Whenever you work with wire, pro- tect the patient’s eyes, because a loose end can spring back and injure them. (1) Close them, and cover them with vase- line gauze and a dressing. (2) When you are not working with the free end of a piece of wire, anchor it with a pair of forceps.Fig. 62.16: FIXING THE MANDIBLE. A, this patient has an undisplaced TWISTINGfracture, so he only needs a bandage. B, keep rubber bands and eyelets DENTAL WIREready in the theatre. C, the steps in making an eyelet. D, the eyelets madeinto hooks and held with a rubber band. E, passing wires between theeyelets. With the kind permission of Michael Wood and Hugh Dudley.FRACTURES WITH SEVERE TISSUE LOSS arch bar beingUsually, there is severe displacement also. Toilet the pa- wired in placetient’s wound, replace the bone and soft tissues as best youcan, and fix the remains of his mandible to his maxilla by hold the wire inany suitable method. Close his wound, suture his skin to his strong artery forcepsmucous membrane, and refer him. and twist them round on your middle fingerINTERDENTAL EYELET WIRING FOR MANDIBULARFRACTURESINDICATIONS Displaced fractures of the mandible with: (1) Fig. 62.17: TWISTING DENTAL WIRE. Use soft 0.35 mm stainless steela sound maxillary arch, and (2) enough teeth opposite one wire, or any convenient soft wire, and take care to protect a patient’s eyes.another to take the wire. Kindly contributed by Frederick Onyango. 13
  • 14. 62 Maxillofacial injuries INSERTING THE EYELETS Look carefully at the facets MORE WIRINGon the patient’s teeth and study the way his jaws fit together. A METHODS FORIf there is any abnormality in the way they occlude, allow for THE TEETHit when you immobilize the fragments. Push an eyelet well down between two teeth (1) as shownin C, Fig. 62-17, bring the ends of the wire back betweentwo adjacent teeth (2), pass one end of the wire through theeye (3), twist both ends together, pulling tightly as you do so,and cut them off (4). Tuck the sharp ends between his teeth. Risdon wiringPull on the eye to bring it nearer to the occlusal surface andmake sure it is secure. B C Fix about five eyelets in either jaw in suitable places, sothat when they are joined by tie wires, these will run diag-onally in both directions and brace his jaws together. Don’tplace the eyelets immediately above one another, or you willnot be able to anchor the fragments. Alternatively, wire the teeth directly as in D, and E, Fig.62-19. This is a quick temporary measure if you have manycasualties, but the wires loosen more easily. D REDUCING A FRACTURED MANDIBLE If there are anyloose teeth in the fracture line, this is the time to remove E Interdental wiringthem. Bleeding sockets will not now obscure the wiring. CAUTION! (1) Control bleeding. (2) If you have intubatedthe patient and his throat is packed, remove the pack beforeyou wire his teeth. Leave his nasotracheal tube down. (3)Suck out his throat before you close his jaw. Reduce the fracture by closing his jaws. When thepatient’s teeth fit together properly, the fragments will bealigned. Place the tie wires loosely at first, and only tighten Fig. 62.18: MORE METHODS OF WIRING THE TEETH. A, B, andthem after you have checked the occlusion. Tighten them C, Risdon wiring—a useful alternative to an arch bar. D, and E, directlittle by little, first in the molar area on one side, then in the interdental wiring—an alterntive to eyelet wiring if you have many casu- alties; it is quicker, but not so secure as using eyelets. After Killey with kindmolar area on the other side, working round towards the in- permission.cisors as you do so. CAUTION! (1) If you tighten the wires firmly on one sideonly first, you will cause a crossover bite. (2) If you tighten METHOD Take two pieces of soft 1 mm stainless steelthe incisor wires first, you will cause a posterior open bite. wire about 25 cm long. In the middle of each piece twist a(3) Don’t twist the wire too tightly on a single rooted tooth, or loop that will fit over one of the posterior teeth of the patient’syou may pull it out. You can exert more tension on a multi– broken lower jaw. Fit the loops over these teeth, and twistrooted one. (4) Make sure that you have not trapped his them secure. Then twist the ends of each wire double. Bringtongue. the twisted strands from each side together, reducing the Finally, run your finger round his mouth to make sure that fracture as you do so. Twist them together in the midline,there are no loose wires which might injure his lips. Coat his so that they lie along the necks of the teeth. Cut the joinedlips and the inner surfaces of his cheeks with vaseline. pieces of wire short. Fix the twisted wires to some individual teeth with 0.35 mm wire loops. Finally, wire the mandible to eyelets placed on the maxillae.ALTERNATIVE METHOD OF EYELET WIRING USINGHOOKS AND RUBBER BANDS FITTING ARCH BARS FOR MANDIBULAR FRACTURESThis is shown in D, Fig. 62-17. Use it when there is anydanger of vomiting, or if a patient has to travel. You will need This is not as easy as it looks! Use a pair of heavy cuttingthicker wire than with eyelet wiring. pliers to cut the bars to the right length for each jaw; try to Surround the neck of every second or third tooth with a make them span as many teeth as possible; and leave themloop of wire. Leave the two ends free towards the lips. Twist long enough for the end to be bent towards the posteriorthem a few times and then make a small hook with the free surface of the last available tooth. Bend them to shape alongends. Make sure they really are smooth. the necks of the teeth with the hooks facing towards one Pass short rubber bands diagonally over these wire another. The patient’s lower jaw will be displaced, so shapehooks. If necessary, cut them from a suitable size of rub- the arch bar for it to fit round his upper jaw, or fit it round theber tube as in B, in this figure. lower jaw of another person with the same size of arch. Use 15 cm lengths of 0.35 mm wire to wire the arch barRISDON WIRING FOR A FRACTURED MANDIBLE to the teeth. It is usually best to start in the premolar region by wiring one tooth on each side. Pass the wires round theINDICATIONS As an alternative to an arch bar for a fracture necks of the teeth and wire as many as you can. Becauseof the mandible that needs fixation. Some surgeons prefer of their shape, incisor teeth are usually difficult to wire, soa Risdon wire to an arch bar. you may have to leave them. If the wire tends to slip off, be14
  • 15. 62.10 Fractures of the angle or body of the mandible FITTING AN exact site of the incision will depend on where his fracture A is. Reflect the skin. Under the incision you will find the su- ARCH BAR perficial fascia and the platysma muscle. Cut across the fibres of his platysma, and use blunt dis- section to find his facial artery and his anterior facial vein. These pass diagonally upwards and forwards across the lower border of his mandible at the anterior edge of his mas- B seter. Retract these vessels gently backwards or forwards away from the line of the fracture. If necessary, cut and tie them. Often, the fracture line will lie just posterior to the C anterior edge of his masseter. If so, retract the vessels an- teriorly. Use a rongueur to strip his masseter and the periosteum away from the lower border of his mandible (B). Define the fracture line. You will probably find that the posterior fragment lies deep to the anterior one and overlaps it. Disimpact the two fragments and remove any oId blood clots and loose fragments of bone, which may prevent you aligning the two parts of his mandible. Now pass your finger under the lower border of the pa- tient’s mandible (C), and separate It from the deep tissues D of the floor of his mouth. Replace your finger with a flat broad retractor in this position (D). Drill a hole in each fragment about 3 mm from the fracture edge—be certain the holes pass through both cortical plates E of the bone. You will feel the drill touch your retractor when this has happened. CAUTION! Don’t make the holes in the middle of the pa- tient’s mandible, or you may injure his inferior alveolar nerve. Keep the retractor blade in place deep to his mandible. Take two 15 cm lengths of wire. Pass the first wire through one of the holes in his mandible from the buccal to the lingual side. Secure it with artery forceps at both ends. Now take a second wire and twist a small eye onto one end. Pass thisFig. 62.19: FITTING AN ARCH BAR. A, bending it to shape. B, fitting eye through the hole in the other fragment of his mandibleit round the maxilla. C, wiring it to the maxilla. D, passing a win round a from the buccal to the lingual side. Thread the deep end oftooth. E, fixing the rubber bands. After R.O. Dingman and P. Navig ’Surgery the first wire through the loop and twist it round itself (E).of Facial Fractures’ W.B. Saunders Co. Publishers, permission requested. Use it to pull the second wire through the first hole. Remove the ’eye’ wire and twist the two ends of the first wire gentlyprepared to raise the gum with a periosteal elevator. Tuck together to reduce the fracture until there is only a hair–linethe ends of the wires aside where they will not injure the crack (F).lips. Fix the arch bars with rubber bands. When you have secured the fracture (G), cut the twisted AN IMPROVISED ARCH BAR Take some paper clips, ends of the wire off short and tuck the cut end into one of theopen them, twist them together, make side hooks on them, holes, so that it doesn’t stick out into the soft tissues (H). Cutpoint these upwards on the top teeth, and downwards on a very fine strip of rubber glove and insert this as a drain.the bottom ones. Fix this improvised arch bar to the teeth Close the wound in layers and bandage it with a light pres-with ordinary stainless steel wire, and pass rubber bands sure bandage. Remove the drain after 24 hours.between the hooks. UPPER BORDER INTEROSSEOUS WIRING FORLOWER BORDER INTEROSSEOUS WIRING FOR MANDIBULAR FRACTURESMANDIBULAR FRACTURES INDICATIONS This is seldom necessary. In bilateral frac-INDICATIONS (1) Control of the posterior fragment when tures insert an upper border wire to prevent the musclesthis has no teeth. (2) Control of both fragments when the pa- pulling the anterior fragment downwards, and making thetient has no teeth or insufficient teeth for interdental wiring. fracture line gape.You will usually need interdental wiring or an arch bar also. METHOD Wire the upper border before the lower one. CONTRAINDICATIONS (1) Established infection of the Make an incision along the crest of the alveolus inside thefracture site. (2) Children in whom unerupted teeth may be patient’s mouth. Drill small holes on either side of the frac-injured. ture line, pass a piece of soft stainless steel wire through it, ANAESTHESIA Endotracheal anaesthesia is essential (A reduce the fragments, and twist the ends of the wire tight.13.2). Cut the ends short and tuck them into the nearest drill hole. METHOD Make a 3 cm incision over the fracture site in Close the incision very carefully, because infection is com-line with the patient’s facial nerve, as in A, Fig. 62-20. The mon. 15
  • 16. 62 Maxillofacial injuries LOWER POSTOPERATIVE CARE FOR MANDIBULAR nasotracheal BORDER A tube FRACTURES WIRING Don’t remove the patient’s tracheal tube until anaesthesia is really light. If you have wired his teeth under general anaes- thesia, send him back to the ward with a nasopharyngeal airway in place and his tongue held with a strong suture. Use a large cutting needle to insert it transversely through the dorsum of the back of his tongue. Lead Its end between his teeth and hold them with haemostats. Some surgeons facial consider this is unnecessary. Lie the patient on his side and artery have a sucker ready, with a tube attached which you can pass down his nasopharyngeal tube. B If he has been starved preoperatively, any vomit will be watery and will pass between his wired teeth. CAUTION! Have wire cutters beside his bed or with the rongeur nurse, in charge. Be sure that the nurses know how to re- C mandible being move the wire, if he wants to vomit. Tell, them to cut the separated subperiostally closing wires, not the eyelets. Later, he will be more com- from the tissue fortable if you nurse him sitting up. underneath this patient’s POST REDUCTION X–RAYS If these are not satisfactory, facial artery correct the malposition as soon as possible. was divided ANTIBIOTICS Give these as described earlier (A 62.7). FEEDING A PATIENT WITH A CLOSED JAW Feed him frequently with liquid food through a rubber tube between D his teeth. Let him suck between his teeth or round the back of his molars. Feeding will be easier if he has a few teeth missing. He will probably lose much weight. If he cannot swallow, feed him through a nasogastric tube. F Careful oral hygiene Is essential to prevent osteomyeli- retractor under tis. Ask him to clean his teeth with a tooth-brush after every the mandible meal. Or, irrigate his mouth with saline or 0.5% chlorhexi- E dine from a Higginson’s syringe. 2nd wire fracture FOLLOW–UP FOR A MANDIBULAR FRACTURE If you being reduced send a patient home wired, tell him to keep a pair of pliers available, so that he can remove the wire if necessary. Ask 1st wire him to reattend regularly, so that his wire can be tightened or renewed. Keep children wired for 4 weeks before you test for union, young adults for 5 weeks, and elderly ones for 7 weeks. If you immobilize a patient’s jaw too long, it will ankylose. TESTING FOR UNION Remove the tie wires and gently test for union across the fracture line. If the fragments seem G hair line crack firm, clean the patient’s mouth and remove the eyelet wires. Leave interosseous wire in place unless it becomes infected. H DIFFICULTIES WITH MANDIBULAR FRACTURES wire ends tucked in If a patient CANNOT OPEN HIS JAW, don’t worry for the first week or two. It will open more easily after a few weeks of active use. If, however, he fails to reattend to have the wires removed, so that his jaw remains closed for too long, his jaw movements may be limited permanently. Encourage him to exercise his jaw regularly and to progressively insert a wooden cone between his teeth, so as to separate them a little more each day.Fig. 62.20: LOWER BORDER WIRING. A, a nasotracheal tube has been If his JAW HAS FAILED TO UNITE, encourage him to ac-passed and the patient’s head turned to one side. B, the periosteum is being cept his disability. Non–union is rare. It may follow infection,removed from around the fracture line with a rongeur. C, the undersurface or be the result of leaving a tooth in the fracture line.of his mandible is being freed from the tissues under it. D, the first drillhole. E, the two pieces of wire joined to one another under the mandible. If his MANDIBLE HAS BECOME INFECTED, give himF, and G, the fracture being reduced. H, the wound ready for closure. John antibiotics (2.7), clean up his jaw as much as possible, re-Maina’s patient. move loose teeth in the fracture site and rewire his teeth. Osteomyelitis is an important complication and is more likely to occur if you fall to fix a fracture, so that the fragments are16
  • 17. 62.11 Fixing mandibular fractures with resinskept moving, of if you try to wire one which is already in- ANOTHER METHOD OF FIXING THE MANDIBLEfected. Prevent it by always giving prophylactic antibioticswhenever the mucoperiosteum is torn. Bridges of compound material Hooks stuck on with between the jaws compound material If his LOWER LIP IS NUMB, it will probably recover.Warn him of the danger of burning his lower lip with hotdrinks or cigarettes. If his TEETH DO NOT MEET when the fixation is re-moved, his malocclusion will probably correct itself if it ismild. If it is more severe, his cusps can be ground away. Ifit is gross, refer him for refracture of his mandible, or the re-moval of selected teeth. If he adopts a bite of convenienceacross a partly healed fracture, it may cause a fibrous union,so refer him for a suitable denture. Fig. 62.21: ANOTHER WAY OF FIXING THE MANDIBLE. A, using If the patient is a CHILD manage his fracture as if he bridges of filling material. B, using hooks. Kindly contributed by W.J. Bailey.were an adult, but remember the following differences: (1)Growth disturbances of his condyles may follow, particularlyin condylar fractures. (2) Don’t use interdental eyelet wiring FIXING THE MANDIBLE IN OTHER WAYSunless he has a sufficient number of firm teeth, either decid- ANAESTHESIA (1) Mandibular block (A 6-3). (2) Ketamineuous or permanent. (3) Don’t use interosseous wires, be- (A 8.1). (3) Diazepam (A 8.6). Atropinize the patient to drycause you may damage his unerupted teeth. (4) Mild mal- his saliva.occlusion will correct itself as his mandible grows and hisdeciduous teeth erupt. A bandage, as in A, Fig. 62-17, maybe all he needs. USING ACRYLIC TO FIX AN ARCH BAR MATERIALS Ordinary cold cure acrylic (’Simplex’), as used by dental technicians to repair broken dentures. This is sup-62.11 Fixing mandibular fractures with resins plied as a liquid monomer and a powdered polymer. Put some of the powdered polymer into a small pot. DropYou can use two types of synthetic resin to fix a patient’s the liquid monomer onto it and stir it with a spatula until it isbroken mandible, as an alternative to wiring it. The method the consistency of putty.is quick, easy, and non–traumatic. Fixing hooks with com- METHOD Sit the patient up in a chair. Make an arch barposite is easier than wiring them directly to his teeth, less from several strands of thick (2 mm) stainless steel wire, andtraumatic, and more comfortable for him because there are fashion it to fit the arch of his mandible, lingually, or buccally,no wire ends to scratch his mouth. or both. Cold curing quick setting acrylic resin is weaker than the To stop the resin sticking, lightly spread vaseline on thecomposite material described below, but is cheap and patient’s lips, mucous membrane and tongue-but not hiswidely available from dental supply houses or dental tech- teeth.nicians. It will allow you to fix an arch bar to a mandible, Hold the arch bar in place with blobs or a continuous wadbut it is not strong enough to let you stick hooks to it. of cold cure acrylic. Lightly spread vaseline on your fingers Composite filling materials of the ’Adaptic’ or ’Isopaste’ type, (to stop the acrylic sticking) and press the acrylic into placetogether with a bonding agent are more expensive and less over the arch bar. Press it firmly between the bases of thereadily available than quick curing acrylic resin. A compos- patient’s teeth. If the arch bar is going to stay in place, theite is supplied as two pastes which you mix together and resin must go between the overhanging parts of his adjacentwhich then set solid. It is usually used for filling cavities, teeth. If he is older, and his gingival papillae have resorbed,but you can use it to make bridges between the teeth of a pa- or he has missing teeth, the resin will be able to pass be-tient’s upper and lower jaw, or you can use it to stick hooks tween them and stick more firmly.to his teeth, and then pass rubber bands or wire over them Hold the arch bar in place until the resin has set (in aboutas with interdental wiring (D, Fig. 62-17). To allow the com- 10 minutes).posite to stick you will have to clean the surfaces of his teethat each fixation point, wash them, etch them with phospho- USING COMPOUND FILLING MATERIAL TO STICKric acid, wash them again, dry them, coat them with a spe- HOOKS ONcial bonding agent, and then press the composite onto them.This is not difficult, but it needs care. Be sure you follow INDICATIONS (1) Conscious and cooperative patients. (2)the instructions exactly. If you use bridges of composite be- This method is particularly suited to unilateral fractures. (3)tween a patient’s jaws, one difficulty will be getting them Recent fractures that will be fairly easy to reduce.into the right position and getting the composite into place CONTRAINDICATIONS Much bleeding which makessimultaneously. Using hooks avoids this difficulty. cleaning and drying the surfaces of a patient’s teeth imprac- At present, proprietary dental resins are unnecessarily ex- tical.pensive, for example, proprietary compound filling material MATERIALS Compound filling material, such as ’Adaptic’costs $75 for 100 g, whereas it only costs $6 to manufacture. or ’Isopaste’ and their special bonding compounds, or theirFortunately, cheaper ’generic’ dental materials are now be- generic equivalents. 50% phosphoric acid, 2 mm stainlessing made, and when they became available this method of steel wire. Rubber bands.fixing mandibular fractures will become more economically METHOD The patient will probably need about six hooksfeasible. depending on the site of his fracture. 17
  • 18. 62 Maxillofacial injuries Sit him up in a chair. Clean the surfaces of his teeth at Join up the hooks with rubber bands or wire. Rubber willeach fixation point carefully, and dry them free of saliva. Use place less strain on the hooks. If you join them with wire,spirit on a pledget of cotton wool, or a dental engine brush. take care not to exert too much force, or you may displace While his teeth are still dry, apply phosphoric acid on a them. After 6 weeks you can chip composite away quitepaint brush for 60 seconds. easily. The last remaining pieces may have to be removed Wash his tooth for 30 seconds, and then dry it again. with a dental drill. Keep his teeth dry with suction, rolls of paper tissue, or ALTERNATIVE NOT USING HOOKS Hold the patient’scotton wool in his buccal sulcus. jaws together with bridges of filling material passing from Apply the bonding material to the dry, etched surface with one jaw to another. You will probably only need about 4a small brush or a wisp of cotton wool. bridges. As they set, keep his jaws aligned and his teeth in Mix a little of the the compound material and the catalyst occlusion.with a spatula on a small paper pad, and immediately pressit into place with lightly vaselined fingers over the preparedsurfaces of his upper and lower teeth. While it is still soft,press a hook into it.18

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