Skeletal Pin Fixation PDF

fracture. Fragments bridged by a bone graft are immobilized by skeletal pin fixation. Fractures in edentulous jaws can be treated in similar fashion. At the time of World War II, skeletal pin fixation became popular for several reasons. The armed services and the British treated simple as we...

fracture. Fragments bridged by a bone graft are immobilized by skeletal pin fixation. Fractures in edentulous jaws can be treated in similar fashion. At the time of World War II, skeletal pin fixation became popular for several reasons. The armed services and the British treated simple as well as complicated fractures by this method, without supplementing it with intermaxillary fixation, so that the transported patient who suffered from motion sickness was not endangered by drowning in vomitus, and limigted duty was made possible without liquid-diet restrictions. Men practing in as well as out of the armed services could treat complicated fractures without having training in open procedures. Skeletal pins can be placed while the patient is under general anesthesia or local block anesthesia or local block anesthesia supplemented by skin infiltration. It can be done in the dental chair or preferably in the operating room, where greater safety and convenience are possible. Strict asepsis is necessary. The skin must be prepared thoroughly, the field must be draped, and the operating team must be scrubbed and wear gloves and gowns. After skin preparation, the inferior and superior borders of the mandible are palpated and marked on the skin with a dye such as gentian violet on an applicator stick. The line of fracture is marked, and the general location of the inferior alveolar canal is marked after reference to the radiograph. Intermaxillary fixation should be placed beforehand if used. The pins are positioned usually by an egg-beater-type drill. Two are placed at a 40- degree angle to each other on one side of the fracture, and two are placed similarly on the other side. If each pin is started 20 degrees from the vertical plane, a 40-degree divergence betweeen them will result. The pins should not be placed closer to the fracture line than 1 cm. The skin is tensed directly over the bone. The pin in the drill is placed on the skin and pressed directly down to bone. The drill is rotated slowly under moderate pressure. The revolving point will be felt to penetrate the outer cortex, transverse the softer spongiosa, and then enter the inner cortex. It should penetrate the entire inner cortex, but it should not be lodged more than 1 to 2 mm in the medial soft tissues. The drill then is removed carefully from the pin. The pin should be tested for stability. If not stable, it has not penetrated the medial cortex and should be rotated deeper with a hand attachment. Two pins are placed in the anterior fragment parallel to the inferior border. The two pins in the posterior fragment can be placed parallel to the inferior border also, provided that the location of the fracture is not so far back that the most posterior pin will be located in the thin bone at the angle of the jaw. If the most posterior pin location is at the angle, it is better to locate the second pin further up on the vertical ramus at the posterior border or in the retromolar area near the anterior border. The pins should be located halfway between the mandibular canal and the inferior border, and care is taken that they do not transverse the facial artery or vein. A bar assembly is attached to the two anterior pins. A similar assembly is placed on the two posterior pins. A large bar is selected and placed in the attachments on the short bars so that it crosses the fracture. The fracture is manually reduced so that the inferior border is continuous to palpation and the lateral border is continuous. All attachments are then tightened securely with a wrench. A drop of collodion is placed around the pin entrances into the skin. Roentgenograms made in the operating room or later will demonstrate the accuracy of the reduction. 21  Properly placed pins will remain tight for several months in the absence of infection. Many variations exist in the design of skeletal pin apparatus. The Thoma bone clamp is useful in cases in which infection makes pins or transosseous wiring uncertain or in long- range treatment cases in which a bone graft is used. Some operators make use of an electrical drill to place pins rather than the manually operated eggbeater-type drill. Open reduction Open reduction with interosseous wiring is a definitive method for anchoring bone segments at the fracture site. Wire is placed through holes on either side of the fracture, reduction is accomplished under direct vision, and immobilization is obtained by tightening the wires. This procedure usually is reserved for fractures that cannot be reduced and immobilized adequately by closed methods. However, fractures that have soft tissue or debris interposed between the fragments and fractures that have healed in malposition are treated by open reduction. One advantage to this method is direct visualization of the fractured parts, and consequently better reduction is possible. Oblique fractures, particularly those that present a short fracture on one cortical plate and a long one on the other plate (usually the lingual), are reduced with more precision. Complicated fractures are treated in this manner. It should be noted, on the other hand, that a severely comminuted fracture is not treated by open reduction if it can be avoided. The many small fragments may lose their vitality and be sloughed after an open procedure because the surrounding periosteal and soft tissue attachments and the traumatic hematoma and its binding, nutritive, and protective functions have been removed, and infection may be introduced. Another advantage is firm fixation. Teeth can loosen, wires and appliances can slip, but the bone ends are still held close to each other. If teeth are present, open reduction should be supplemented by intermaxillary fixation for additional stabilization. Experience has shown that direct interosseous wires cannot be relied on for complete immobilization of the fragments if unrestricted use of the jaws is permitted. Open reduction is done almost always under general anesthesia in the operating room. Intermaxillary wiring should be in place. For that reason, nasoendotracheal anesthesia is indicated. The most common site for open reduction is at the angle of the mandible, and the description will be for that procedure. Preparation of the site of surgery, draping, and the surgical approach through the skin and soft tissues have been described in Chapter 2. The basic armamentarium is supplemented with the following instruments necessary for interosseous wiring: 2 Periosteotomes, dull and sharp 1 Bone rongeur 1 Mallet, metal, small 3 Chisels 1 Pliers, cutting, wire 4 Forceps, bone, Kocher's 1 Retractor, malleable, narrow 1 Pistol drill, key, and drill points Wire, stainless steel, 24 and 30 gauge. 22  Infiltration of the skin with a local anesthetic solution containing 1:50.000 epinephrine or another vasoconstrictor will eliminate clamping and tying the skin blood vessels, resulting in a smoother postoperative skin wound. The bone is exposed, and the fracture is visualized (see Chapter 2 for technique). The posterior fragment usually will be malplaced in a superior and medial position. Examination should be made of the cortical plates, particularly on the medial side. If the medial cortex is missing for some distance on one fragment, the location of the bur holes will have to be moved back until both cortical plates of the fragment can be traversed by one hole. A flat ribbon retractror is placed under the medial side of the bone from the inferior border to protect the underlying soft tissue structures. The second assistant holds the superior soft tissue retractor across the face with the right hand and the ribbon retractor at the inferior border of the jaw with the left hand. The first assistant holds a syringe of normal saline solution in the right hand and the suction (if it is used) in the left hand. The operator holds the drill in both hands. Occasionally secondary tissue retraction by the right hand of the first assistant is necessary near the drill bit. An electrical drill is used more commonly than a mechanical eggbeater-type drill. The first hole should be started on the anterior fragment, near the inferior border, 0.5 cm from the fracture site. The drill point should be sharp. Rotation is started at slow speed until the hole is started, and then the speed may be increased, taking care that burning of the bone does not occur. The operator will feel the penetration of the outer cortex, the spongiosa, and the inner cortex. Saline solution is sprayed on the site during drilling. The drill is removed. Another hole is placed above the first one in the anterior fragment. It should not go through the inferior alveolar canal being slightly below it. Usually it is well to place a 24-gauge wire in this hole immediately after the drill is removed and clamp the two ends with a hemostat outside the wound. The ribbon retractor is repositioned under the posterior fragment. One hole is placed near the inferior border 0.5 cm from the fracture site. Another hole is placed as high as possible above the first one and still just below the inferior alveolar canal. A wire is placed through this hole and clamped outside the wound. The ribbon retractor is repositioned under the posterior fragment. One hole is placed near the inferior border 0.5 cm from the fracture site. Another hole is placed as high as possible above the first one and still just below the inferior alveolar canal. A wire is placed through this hole and clamped outside the wound. The medial arm of the wire in the anterosuperior hole crosses the fracture line and is threaded in the posteroinferior hole from the medial to the lateral cortex. It usually is difficult to locate the hole from beneath. Time can be saved by placing a thin 30-gauge wire in the second hole from a lateral to medial direction. This wire is doubled, and the loop is introduced into the hole first. When recovered with a small curved hemostat from the medial aspect, the medial arm of the original wire is placed through the loop and bent back 3 cm. The thin double wire then is pulled upward (laterally) with care, to thread the original wire through the hole. The two arms of the original wire then are clamped outside the wound. The medial arm of the wire in the posterosuperior hole is threaded through the anteroinferior hole from a medial to lateral direction, using a similar thin wire loop technique. It is clamped outside the wound. 23  The bone fragments are grasped with bone-holding or Kocher's forceps, although two No 150 dental forceps may be employed, and the fracture is reduced by manipulating the fragments. If aberrant soft tissue and other debris are located between the bone fragments, it should be removed at this time. If necessary, major debridement should be done before the wires are placed. The wires are tightened while the assistant holds the bone ends int he reduced position. It is important to place upward traction on the needle holder while twisting the wires. After the wire has been tightened to within 3 mm of the bone surface, a small periosteal elevator is placed on the underside (medial) of the bone and the wire flattened against the bone. The needle holder grasps the strand of wire at the next to last turn, upward traction is made, and the wire is turned down to the bone surface. The same procedure is followed for the other wire. The first wire is examined for tightnessč. The bone-holding instruments are removed, and the fracture reduction is inspected. Ordinarily no further manipulation will be necessary. The wire strands are cut off at a length of 0.7 cm, and the ends are turned carefully into the nearest bone holes. Soft tissue closure is made by layers as described in Chapter 2. No drains are placed unless uncontrollable oozing of blood from deep areas is noted when the platysma muscle layer is being closed. After the skin sutures are placed, a small piece of sterile Teflon is laid over them. Three 10 by 10 cm gauze sponges are placed over the Teflon and held. Drapes are removed together with gloves and operating gowns. Blood and secretions are wiped from the face and neck. Skin areas adjacent to the bandages are painted with compound tincture of benzoin and allowed to dry. Many narrow strips (1 cm) of adhesive tape 20 cm long are placed over the bandages and skin with a fair amount of tension, since a pressure dressing is desired. An operating cap is placed on the head of the patient. A roll of elastic adhesive tape is wrapped around the chin, bandage, and head in modified Barton style. Last, a 10 cm strip of ordinary adhesive tape is placed on the cap over the forehead, and the words "fractured jaw" are written upside down on it. This will remind recovery room personnel that the ordinary practice of holding the chin up to maintain a clear airway must be done with care, if at all. It is possible to place too much bulk and pressure with the elastic adhesive dressing on the anterior throat instead of under the chin. Immediate respiratory embarrassment will result, necessitating revision. The endotracheal tube should not be removed until the elastic adhesive dressing is in place. Anesthesia should be continued in sufficient depth until that time so that the patient will not "buck" on the tube. A carefully reduced fracture can be disturbed by "bucking" on the tube, particularly if the fracture is not supported adequately by outside bandaging. The postoperative orders should be written in the operating room. In most hospitals all preoperative orders are automatically cancelled by an operative procedure. This basic technique has many variations. Three bone holes are adequate usually. This eliminates the need for the anterosuperior hole, with the attendant threading of the wire immediately after drilling. All three holes are drilled. The posterosuperior hole is drilled last, and a wire is placed through it. The medial arm of this wire in the posterosuperior hole is threaded into the anterior hole. Then one wire is placed from the anterior hole to the posteroinferior hole. Two wires therefore are located in one anterior hole. The horizontal wire is tightened first to impact the bone, and then the oblique wire is tightened to prevent upward muscle displacement. The first wire is examined for stability, since it often requires another 24 turn. In the three-hole technique, a figure-of-eight wire in two inferior holes offers advantages in providing downward traction as well as cross fracture traction. As a matter of fact, the technique used most today employs two holes, one on either side of the fracture, connected with a figure-of-eight wire. A figure of eight is made on the inferior border, with the wires crossing near the fracture site. Both ends of the wire can be placed from the lateral side, eliminating the threading from the medial side. Bone plates are used infrequently in new fractures of the jaws. Healing seems to be delayed in comparison with wire techniques that pull the fractured ends together during convalescence. The screws in bone plates hold the bones rigidly. The technique of fastening the plates sometimes will allow a small distraction of the fragments, and the absence of minute functional stresses at the fracture site results in slower healing. Care must be taken that the screws and the plate are made of exactly the same alloy to prevent electrolytic currents from forming, which would cause dissolution of bone around the holes. Even screws cast from the same alloy sometimes cause such currents. In the casting process the metals may have separated somewhat so that the head and point of the same screw are not a uniform alloy. In comminuted fractures that require open reduction and occasionally in edentulous mandibular fractures that have a strong tendency to override, a metal gutter plate can be placed on the inferior border with screws or wires through bone holes. Ordinary wires without a bone plate will pull an overriding fracture together, but they will not hold an overriding fracture in proper distracted position unless other wires are placed in lateral directions. The principle of the slotted plate used by the orthopedic surgeon in fractures of the long bone is applicable here. Muscular pull across the fracture site is allowed to act to keep the fractured ends together during healing by the sliding of screws in a horizontal slot rather than in a hole in the plate. The L splint has a right-angle bend across its top surface that is placed in a slot cut through the cortical plate across the fracture zone. Because of its horizontal stability, only two screws are necessary. The L splint is less bulky and more stable than ordinary bone plates. Treatment of fractures of the mandible Uncomplicated fractures A large percentage of mandibular fractures can be treated by simple intermaxillary fixation. The fractures must be located within the dental arch, and at least one sound tooth should be present in the posterior (proximal) fragment. Although specific advantages are inherent in the use of one method over another in a specific fracture, by and large any method of intermaxillary fixation can be used. For example, multiple-loop wiring was used extensively and almost exclusively in the armed services during World War II. The beginning practitioner should be able to manage one method well. Variations can be considered with increased experience. The question of the removal of a tooth in the line of fracture is managed often by the judgment of the operator. Before the sulfonamides and antibiotics, it was always removed. Most experienced practitioners still will remove this tooth. The following factors influence the decision: the absence of fracture or gross injury to the tooth; the absence of caries or large 25 restorations; the absence of periodontitis; the location of the tooth, including esthetics and the possibility of arch collapse; the nature of the fracture; and the probability of adequate response to antibiotic therapy. If serious doubt exists whether or not to extract the tooth, it should be extracted. Persistent chronic infection or an acute abscess occurring later in treatment sometimes will require opening of the fixation to extract the tooth. Delayed union or nonunion can result. As a matter of fact, infected and grossly carious teeth that are not in the line of fracture should be extracted before placing intermaxillary fixation. This can be done while the patient is under the same anesthesia given for wiring. Elastic traction is placed to overcome distraction and muscle spasm. With continued changing, elastic traction can be used throughout convalescence. If desired, the elastics can be replaced by intermaxillary wires after 1 week. The wires are easier to keep clean, and they seem to bother the patient less. Recalcitrant patients who desire a chicken dinner at the end of the third week sometimes require intermaxillary wire fixation supplemented by elastic traction. Antibiotics are useful for the first week as a prophylactic measure. It is advantageous usually to admit a fracture patient to the hospital. Many patients with simple fractures are treated in the outpatient clinic or office and then allowed to go home, where they are observed. However, a 24- or 48-hour admission will allow the patient to recuperate from his trauma and operation better, his new diet and drug therapy can be introduced to him, and he can be observed more closely. Complicated fractures Fractures that cannot be reduced and fixed properly by simple intermaxillary fixation require further measures. Usually the dentulous cases have intermaxillary fixation placed as a starting point. Mandibular angle. Intermaxillary fixation is placed. The horizontal and vertical favorable fractures require no further treatment. A solid, unfractured tooth in the posterior fragment with an antagonist in the maxilla will preclude further treatment. Conservatism is necessary in condemning such a tooth for extraction. Many experienced practitioners on occasion have reatined such a tooth when one root has been fractured, but as a rule the worry during the convalescence period does not make the procedure worthwhile. The oral surgeon who enjoys life treats the fracture in definitive fashion immediately. Many methods for controlling the posterior fragment have been advocated. Some have been abandoned, and others are not generally accepted. Skeletal pin fixation and open reduction are the two main alternatives. Individual preference is a strong factor in choice. Skeletal pin fixation is satisfactory if it is placed properly. Pin fixation can be done in the office if necessary. The fact that much external hardware is in evidence during healing and the fact that open reduction takes only about 30 minutes longer to do influence many oral surgeons toward open reduction. Open reduction, despite its drawbacks of the external scar, the loss of the original hematoma, the exposure of bone to possible infection, and the operating room procedure involved, still seems to provide more definitive treatment. Two alternative intraoral methods are illustrated. Occasionally a circumferential wire can be placed through a hole in the posterior fragment through an intraoral incision and the 26 wire looped around the inferior border. The angle of the fracture line must be suitable. The other method involves placing two intraoral holes in the buccal cortex of the bone after removal of the third molar. This method is valuable in the case of mandibular fracture associated with removal of an impacted third molar. The wire should lie in a vertical plane rather than a horizontal plane. The technique is especially successful in the horizontal favorable fracture. Symphysis. Simple wiring often provides satisfactory immobilization. Wiring of the teeth, particularly with the Risdon wiring across the fracture, will reduce the fracture adequately at the alveolar level, but separation or telescoping may occur at the inferior border. If the wiring is tight and the inferior border separation is minimal, healing will be satisfactory. However, the principal complication is collapse of the alveolar arch inward, which is difficult to prevent with dental wiring. A simple acrylic splint placed on the lingual aspect of the dental arch before wiring will prevent arch collapse. Wide separation or other malposition requires further treatment. Skeletal pins can be used. A Kirschner wire or Steinmann pin can be driven across the chin by an electrical drill. This is done through the skin surfaces while the fracture ends are held in proper reduction. This is a relatively simple procedure that takes little time. Open reduction in this region does not encounter large vessels, but the tissue attachments are difficult to raise. Care must be given to locating the linear scar beneath the chin within the skin creases if practicable. More exact reduction and closer fixation are made possible by open reduction. This method is valuable, especially in the grossly telescoped fracture. In symphysis fractures uncomplicated by condyle fracture, force of the blow has traumatized the temporomandibular joint, and ankylosis can occur if the jaw is not opened occasionally during the treatment period to free the joint. This maneuver is accomplished better if a lingual acrylic splint stabilizes the symphysis fracture. Edentulous fracture. Circumferential wiring around a denture or acrylic splint is adequate in most cases. All fragments must be covered by the denture base, and they must be held adequately to preclude auxiliary treatment. Fractures occurring distal to the posterior border of the denture, old telescope fractures, and cases of severe trauma require skeletal pin fixation or open reduction. Some oral surgeons do not place dentures and intermaxillary fixation in edentulous jaws when skeletal pin fixation or open reduction is done, although others feel that all jaw fractures should have intraoral stabilization. In the case of the angle-third molar region fracture that is not distal to the posterior border of the denture, the circummandibular wires should be placed around the anterior fragment. Muscular pull on the posterior fragment will elevate it so that further wires are not necessary in this area. Keeping the maxillary denture in is often a problem. If the maxillary denture fits wells, and particularly if it has one or more minor undercuts, the two dentures connected by intermaxillary fixation may stay in place. Older women with resorbed alveolar ridges will carefully slip the maxilla out of the assembled dentures when the surgeon has gone, turn to the next bed, and start to jaber incessantly. This is an eerie sight with the dentures closed and still moving in unison over fast speech. If the surgeon does not drop in unexpectedly he or she will find the jaws always fixed in position and will wonder why the fracture heals slowly, 27 if at all. A head bandage worn continuously is uncomfortable. The cooperative patient can wear an elastic support over the head and chin at night or even during the day. The uncooperative patient will require further stabilization. A simple method consists of direct wiring to the piriform fossa margins. With the patient under local anesthesia or general anesthesia supplemented by infiltration anesthesia, an incision is made high in the labial fold next to the midline of the maxilla. The bone is exposed by blunt dissection. The inferior border of the piriform fossa is followed laterally until the lateral border is reached, where a small hole is placed with a bur. Thirty-gauge wire is placed through the hole and brought out untwisted through the incision. The incision is closed with No 3-0 catgut. The same procedure is carried out on the other side. The denture is removed from a cold-sterilizing solution and placed in the mouth. The wires are threaded through previously drilled holes in the labial flanges of the denture and tightened moderately. Dental compound is placed over the rosette, and a pressure bandage is placed over the lip. Pernasal wiring is another method for fixing a denture to the maxilla. A heavy awl is passed just inside the external nares directly through the mucosa and bone of the nasal floor and palate with simple pressure and rotation. A wire is looped through the eye of the awl at its point of emergence on the palatal side. The instrument is withdrawn upward through the palate, but only to a point just beneath the nasal epithelium. It is then guided anteriorly and inferiorly through the labial mucosa into the height of the vestibule. The wire is removed from the eye of the awl, the awl is withdrawn completely, and the two free wire ends (one palatal and the other vestibular) are drawn together around the prosthesis, drawn through a palatal bur hole in the appliance, and tightened on the labial surface. Circumzygomatic wires are useful also. A long, sharp instrument with a hole near the tip is introduced at the height of the buccal fold just distal to the maxillary first molar region and is pushed upward and posteriorly. A finger on the skin over the zygomatic arch guides the point medial to the arch to emerge on the skin. A wire is threaded into the eye of the instrument, and the instrument is withdrawn into the mouth. The wire is disengaged. The instrument is introduced into the same oral wound and pushed in the same upward direction, this time to pass on the lateral side of the zygomatic arch and emerge through the same skin wound. The other arm of the wire is threaded into the eye of the instrument, and the instrument is withdrawn. The two arms of the wire are sawed back and forth until they contact bone, and they are attached to the maxillary denture flange in the molar region. A similar circumzygomatic wire is placed around the opposite zygomatic arch. The wires can be looped around the mandibular circumferential wires that secure the mandibular denture to the lower jaw. Open reduction of an edentulous fracture is done best with four holes, using heavy wire. If a triangular segment of bone is found on the inferior border (a not uncommon occurrence in edentulous fractures) and telescoping has occurred, a gutter bone plate on the inferior border will support the segment. Skeletal pin fixation is excellent. The thinness of the bone makes placement difficult at times. 28  Multiple fractures Multiple fractures, in which four or more jaw fractures are present in the same person, occurred in 17% of the fractures in the District of Columbia General Hospital series. When multiple fractures occur in both jaws in the same patient, it is difficult sometimes to find a starting point for treatment. Many fragments at different occlusal levels require the establishment of a baseline, which is usually the mandible. The rule is "bottom up and inside out". After the parts of the mandible have been reduced to a satisfactory plane of occlusion, other segments are fitted to it. If many mandibular segments are present, and if the maxilla is severely fractured so that it cannot be used to establish a plane of occlusion, impressions of the teeth are made and casts are poured. The casts are cut at the fracture lines and reassembled in normal occlusion, and a cast splint that has proper indentations on its superior surface to support the maxillary teeth is made for the mandible. Multiple fractures that occur solely in the mandible often can be assembled by fixing the teeth of the individual segments to the intact maxillary arch. Wiring or divided arch bars are used. However, many teeth often are lost in this type of fracture. A splint may be used for greater stability, but the splinted mandible in this case is wired to the maxilla to obtain and maintain good occlusion. Oblique fractures and horizontal fractures appearing on the inferior border are treated by circumferential wiring around the splint. Skeletal pins are difficult to place in many small fragments. Open reduction is a last resort. It is definitive treatment, but many small pieces are difficult to wire, and surgical exposure will deprive them of any last vestiges of mechanical and physiological support afforded by the surrounding soft tissues. Fractures of the coronoid process (2% of the District of Columbia General Hospital series) often are not treated if no displacement has occurred. Tendons of the temporal muscle frequently are inserted low on the ramus, which will prevent displacement. If upward displacement does occur, open reduction can be done through an intraoral approach. An incision is made on the anterior border of the ramus, and direct wiring utilizing two holes is done. If reduction is not possible and impairment of function is present, the coronoid process is removed. Condyle The fractured mandibular condyle has been treated for many years by a closed procedure. Intermaxillary fixation is placed that immobilizes concomitant fractures and corrects the displacement of the jaws associated with the condyle fracture, that is, a shift of the midline toward the side of the fractured condyle and a slight premature posterior occlusion on that side. The fractured ends of the bone in the condylar region thereby are placed in a somewhat better relationship. Because of muscular pulls and the stress of the blow, the condylar head often is dislocated forward or tipped medially out of the glenoid fossa. Often the fractured neck of the condyle remains close to the fractured ramus portion. In a subcondylar fracture the fractured segment remains upright in a position lateral to the ramus. Attempts at intraoral as well as extraoral manipulation, the latter including lateral pressure by a sharp instrument through the skin ("ice-pick technique") and various pressure pads on the skin, are usually unsuccessful. Because of trauma to the joint structures, an ever-present danger exists of ankylosis of the condyle to the glenoid fossa. Healing in proper occlusion under intermaxillary 29 immobilization is allowed to progress for 1 week. At that time, with the patient in the dental chair, the jaw is opened carefully once by the operator rather than the patient, care being taken that other fractures do not move, and fixation is again applied. This is done several times in the following weeks. The effect of this procedure is to ensure motion in the condylar area. Joint surfaces are mobilized so that hemorrhage and edema fluid brought into the joint by trauma are not allowed to organize into a bony ankylosis. The objective is to move the joint without moving the lower fractured bone surfaces, which would lead to nonunion. Such manipulation during healing will create movement in the joint rather than in the fracture zone if it is done carefully, and primary healing of the fractured parts will occur with no ankylosis in the joint. If the fracture occurs inside the joint capsule, weekly movement of the parts (sometimes more frequently) is especiallhy necessary to prevent ankylosis. In this case, because joint and fracture are together, movement may disrupt the condinuity of the fibrous callus in the condylar fracture area. Fibrous tissue rather than bone forms at the junction. The fractured condylar head treated in this manner is nonfunctional. Because of this factor, together with a traumatic hematoma and the damaged synovial membranes, it ankyloses to the base of the skull. The ramus articulates on the edge of the condylar fragment by a fibrous joint. The functioning of the contralateral joint, together with the stability afforded by the fibrous joint, allows satisfactory functioning in good occlusion. The patient can bite as hard on the side of injury as on the other side without experiencing pain. The head of the condyle that is displaced medially out of the glenoid fossa will ankylose if it touches bone. It is held in place by the soft tissues. Years later it seems to disappear. Fibroous tissue fills the joint cavity. The occluding dental arches attached to a normal contralateral joint will not allow the ramus to move further upward to form an open bite, whether or not an ankylosed condylar fragment is present in the fossa. Evidence suggests that an attempt is made over the years to re-form the missing condyle from the remaining ramus portion. Open reduction of condylar fractures has become popular since World War II. The condylar head is placed back in its original position in the glenoid fossa and wired to the ramus. Healing of the fracture takes place by direct bony union, and the healed member functions on the true joint rather than on an artificial fibrous joint. The surgical procedure for the preauricular approach is made according to the description given in Chapter 2. Dissection is carried down to the articular capsule. Manual movement of the jaw at this time will demonstrate the joint structure. The capsule is incised horizontally if the fracture is intracapsular or if the condyle has been displaced medially out of the glenoid fossa. This is necessary for access. It is advantageous not to incise the capsule if possible, since the lateral side of the capsule is stronger than the medial side, and the intact capsule stabilizes the condylar head. A hole is placed in the fragment that lies most superficial. Special retractors such as those designed by Thoma are placed beneath the fragment to protect the maxillary artery. The ramus of the jaw may be pushed upward into the wound to visualize the inferior fragment better and distracted downward to gain access to the superior fragment. A hole is then placed in the other fragment. 30  The condylar fragment is repositioned carefully in the glenoid fossa. The management of this fragment is a delicate procedure. The fragment is difficult to find if it is displaced deeply to the medial side. It must be placed in its properly oriented position in the fossa with as little damage to surrounding structures as possible. It must be held firmly while the whole is drilled. Any excessive pulling will bring the fragment completely out of the wound. A wire is placed through the two holes, threading it from the lateral surface of the condylar fragment first and recovering it from the medial surface to the lateral surface of the inferior fragment by means of a thin wire loop. The wires are twisted over the reduced fracture. It is well to remove the attachment of the lateral pterygoid muscle to prevent redislocation of the condyle. Thoma immobilized the severely displaced condyle that has few if any attachments by means of a catgut suture through holes to the glenoid fossa or by skeletal pin fixation between the condylar head and the eminentia articularis. The wound is closed in layers, with particular attention to good closure of the articular capsule. A pressure bandage is placed over the wound, and a head bandage made with elastic adhesive tape is placed before the anesthesia is lightened. The endotracheal tube is removed before the patient "bucks" on it. The submandibular approach is used if the fracture is situated outside of the capsule at the base of the condylar neck. As a matter of fact, this approach is recommended for most cases of open reduction of the condyle. For a description of the surgical approach see Chapter 2. The fracture site can be exposed well with long, narrow-angle Army-Navy retractors. It may be necessary at this stage to administer curare, 60 to 90 units, or succinylcholine hydrochloride, 20 mg, intravenously to provide muscular relaxation. The same general technique of direct wiring, using two holes, can be employed as described previously. The thin fragments in the condylar neck are usually telescoped. Therefore the ordinary placement of wires will further telescope the fragments rather than hold them distracted in correct position. A small amount of telescoping of the fragments does not seem to affect correct function, particularly in the presence of poor dentition. Lateral contact of the bone ends is important to healing, although the healing is slower. Several methods to overcome telescoping are employed. A figure-of-eight wiring offers some advantage. If one cortex is longer than the other, one hole is drilled through both fragments and the fragments are wired together. A rounded gutter plate can be placed around the posterior border and wired into place, or a flat, three-pronged plate can be screwed into the lateral surface. The lateral pterygoid muscle attachment often is removed surgically to prevent subsequent dislocation through muscle spasm. Surgical closure of the wound and the immediate postoperative treatment are similar to the procedures described previously. The Chalmers J Lyons Club in 1947 reviewed the postoperative results of 120 cases of fractured condyles. They found that fractures treated by closed procedures healed satisfactorily without accurate alignment of the fragments, that ankylosis occurred infrequently, that disturbances to epiphyseal growth did not appear among the younger or skeletally immature patients, and that conservative methods of closed reduction and intermaxillary fixation were simple and effective. In a 5-year survey of 540 jaw fractures at the District of Columbia General Hospital, 115 cases of condylar fracture were found with a total of 123 condylar fractures (8 being bilateral). Of these, 16 were intracapsular, 64 were extracapsular, and 43 were subcondylar (a total of 107 extracapsular fractures). Thirteen cases were in children. Condyles were 31 fractured in 21% of all cases of jaw fracture. Treatment was as follows: no treatment, 14 cases; conservative treatment, 96 cases; and open reduction, 12 cases. One case of postoperative ankylosis developed in a conservatively treated case. The general consensus today in the management of the condyle fracture is toward conservative (that is, closed) treatment. This is particularly true in the unilateral case. No figures are available to indicate the percentage of ankylosis after open reduction of the condyle, which would necessitate later resection of the condyle. This seems to be an infrequent complication. However, function after the open procedure does not seem to be better than that after the closed procedure, in spite of the rather time-consuming procedure in a hazardous location. The bilateral case presents a different problem. If proper ramus height is afforded by a nondisplaced condylar fracture on at least one side, open bite may not result. If ramus height is collapsed on both sides, consideration should be given to an open procedure on at least one side. If a low extracapsular fracture occurs on one side, that side should be opened through a submandibular approach. True temporomandibular joint function then will be made possible through direct bone healing on the one side. Both sides can be wired directly if the fractures demand it. Smith and Robinson presented an interesting case of bilateral joint fracture. The fractures occurred several years apart. Repeated intermaxillary wiring for a total of 3 years and 6 months was followed in each instance by open bite when the wires were removed. When the patient was presented to them, they performed a bilateral joint reconstruction by placing in each glenoid fossa a piece of bone that was designed to ankylose to the fossa and to the ramus. Later the two sides were resected at the graft-ramus junction and preformed metal guide plates were placed to form joint surfaces. Function was excellent. Observation is continuing on condyle fractures in children. The main growth center of the jaw is located in the condylar region. A study conducted elsewhere was said to show that portions of the growth center in rats extended some distance down the posterior border of the ramus. For this reason, the separation of the growth center from the rest of the jaw is being studied. The mandibular growth that is associated with the condylar growth center occurs between 1 and 5 years of age in the human. A period of quiescence occurs from 5 to 10 years of age, followed by another period of active mandibular growth from 10 to 15 years of age. This latter growth is associated with muscular function more than with the growth center, which is not so important at this age. By this reasoning the most critical period for a condylar fracture would be from 1 to 5 years of age. Perhaps the most critical situation is a fracture- dislocation in a child 2.5 years old or less. Numerous clinicians have presented radiographs showing re-formed rami after closed treatment of condylar fractures. Such reconstruction takes place in conformity with Wolff's law that the shape of the bone conforms to the stresses placed on it during function. The process takes years to accomplish the end result. Fractured jaws in children Two considerations are primary in the management of fractured jaws in children. Deciduous teeth are difficult to wire, and growing jaws heal exceedingly fast. 32  Deciduous teeth have a bell shape. The widest portion of the tooth is at the neck, where the wires are placed. For this reason, many oral surgeons did not attempt to wire deciduous teeth in the past, turning to the use of acrylic splints instead. The splint has the advantages of stability and the elimination of time spent in wiring the patient under general anesthesia. However, often the splint requires the use of circumferential wires. The main disadvantage is the time needed for construction, although if several sizes of preformed acrylic splints are available, one can be selected and adapted with dental compound for immediate insertion. Healing usually is complete in 3 to 4 weeks. If nearly a week is required for impressions and laboratory construction of the splint, the preliminary organization at the fracture site is broken up during reduction and placing of the splint. The use of a finer wire (28-gauge) makes the wiring of deciduous teeth possible. If the permanent first molar and anterior teeth have erupted, retention is made easier. Malpositioned angle fractures occurring in children are treated by open reduction. Condyle fractures are treated conservatively in most instances. Intermaxillary fixation is placed while the patient is under general anesthesia or heavy sedation. It is maintained for 2 weeks, and the fracture then is examined. No fixation has been used in isolated instances, with apparently satisfactory results. Feeding problems The diet is a high-protein, high-caloric, high-vitamin diet in liquid or semiliquid form. A successful sample diet* containing 2.100 calories is as follows: Breakfast Fruit juice - 1/2 cup Cereal - 1/2 cup cooked, thinned with 1/2 cup milk, sugar to taste Milk - 1 cup Coffee or tea as desired Midmorning Milk shake (4 level tbsp of protein-vitamin-mineral supplement in 1 cup whole milk) Lunch Meat - 6 tbsp thinned with 1/2 cup broth or bouillon Vegetable - 1/4 cup thinned with 1/4 cup vegetable juice Potato - 1/4 cup mashed potato thinned with 1/4 cup milk Fruit - 1/4 cup thinned with 1/4 cup fruit juice Cocoa - 1 cup Coffee or tea as desired Midafternoon Milk shake (4 level tbsp of protein-vitamin-mineral supplement in 1 cup whole milk) Dinner Same as lunch, but substitute 1/2 cup strained cream soup for potato Bedtime Milk shake (4 level tbsp of protein-vitamin-mineral supplement in 1 cup whole milk) 33  Food selections Beverages: Milk, cocoa, and milk shakes; fruit and vegetable juices; coffee, tea, etc, only if they do not interfere with schedule Cereals: Cocoa Wheats, Cream-of-Wheat, Farina, Malt-o-Meal, Cream-of-Rice, corn meal - thinned with milk Fruits: Applesauce, apricot, peach, pear - strained and thinned with fruit juices Fruit juices: Apple, apricot, grape, grapefruit, orange, pineapple, tomato Meat: Beef, lamb, pork, veal, liver - strained and thinned with broth or bouillon Vegetables: Beets, carrots, wax beans, green beans, peas, asparagus, spinach, mashed squash - strained and thinned with vegetable juice Vegetable juice: Can be the water used in cooking, or liquid from canned vegetables, or commercially prepared vegetable juices Cream soup: Make with strained vegetable and milk, or use commercial soup thinned with milk Seasoning: Sugar may be added to tart juices or any seasoning used in any foods to suit your taste Instructions to patient: Follow the feeding schedule above, selecting foods from the accompanying list. Larger amounts may be taken, but be certain to follow the basic meal plan. For the strained foods you can use prepared baby foods or you can liquefy common table foods in a mechanical blender. Potatoes can be mashed or strained by hand. Important: The three protein-vitamin-mineral nourishments ensure nutritional adequacy in this liquid diet and must be taken. Additional liquids and beverages may be taken, provided they do not interfere with feeding schedule. * Courtesy Dietene Co, Minneapolis, Minn. The patient should be fed six times a day. He is unable to obtain enough nourishment in the ordinary regimen of three meals a day. Perhaps this is associated with the small particle size, which eliminates bulky pieces in the diet. A calorie chart is important to the fracture patient. He should know how many calories are present in each ounce of the special mixture and how many are in supplementary foods and beverages. He should know also how many calories are necessary to maintain his weight at his present level of activity. The decision then is made whether he should maintain his present weight, gain, or lose weight. Some individuals will lose weight when loss is not indicated, and attention should be given to supplements that will make the diet as attractive as possible. Other persons will gain a tremendous amount of weight, especially with ice cream soda supplements. Some individual who are overweight will use this situation to lose weight deliberately. This should be encouraged if the amount of loss each week is not too drastic and the patient receives adequate nourishment. 34  Many modern food advances have a place in this program. Milk and egg powders and protein supplements make nourishment possible without great quantity. The electric food blender makes possible a balanced diet of the same foods that the rest of the family eats rather than the monotonous dairy food diet. The meal is made more palatable by the electric blender because the individual vegetable and meat can be served as separate servings rather than as a nonspecific conglomeration. A soup preceding and a liquid dessert after the meal constitute a normal fare, except for particle size. The importance of meat in the diet is emphasized by faster healing, especially if the meat is not over cooked. Meats canned for babies are excellent if a food blender is unavailable, although they are expensive. Intravenous feeding with a supplement of 5% protein hydrolysate and vitamins is the method of choice for the first 24 hours after the treatment of a fracture with intraoral complications or for a severely injured patient. This method keeps food out of the mouth until preliminary healing can take place, and it keeps food out of the stomach. A Levin tube placed into the stomach through the nose will allow feeding into the stomach and still keep food out of the mouth. It is a good method of feeding in the first few days after operation if oral wounds are present. The patient who has an uncomplicated fractured jaw usually is better off to start with the diet for fractured jaw as soon as possible rather than to be fed intravenously. Ordinary spoon-feeding or a large-bore glass straw is satisfactory. Most patients have one or more teeth missing, and through these spaces the food material can be placed. If no teeth are missing, the food material is brought by means of a straw into the oropharynx through the space existing behind the last molars. When the patient is recuperating well, usually he will want separate blenderized fods by spoon. The larger the entrance space the larger the particle size and the more bulk admissible, which avoid constipation. An old adage states that as soon as the hospitalized fractured jaw patient complains about his food, he has recovered enough to go home. Time for repair Most mandibular fractures heal well enough to allow removal of fixation in 6 weeks. Occasionally the young adult will require only 4 or 4.5 weeks. Children require 3 to 4 weeks. Oral hygiene is difficult to maintain during immobilization. During hospitalization the mouth should be sprayed by means of a 10-pound pressure spray on a dental unit at least once each day. The patient must irrigate the mouth after every meal with saline solution, preferably with a Water Pil. The use of a soft brush is excellent. Failure to keep the mouth clean in a patient who is lying down will permit material to enter the eustachian tubes and allow a middle ear infection to start. The outpatient can have his mouth irrigated with a power spray once or twice each week. Elastics should be changed weekly. Wires that irritate the lips and cheeks should be turned and the ends protected by dental compound, gutta percha, wax, or quick-cure acrylic. Pain during healing is not common. For the first few days a satisfactory analgesia level is obtained by giving one 300 mg tablet of aspirin each hour for 4 consecutive hours to obtain a satisfactory level and one tablet every fourth hour to maintain the level. Eacg day that analgesia is needed, the aspirin level should be built up by taking 1.2 g of aspirin in 4 hours and then maintained as just outlined. Some patients may not be able to tolerate this amount 35 of salicylate. However, this method has been found by pharmacologists to be as equally effective as 30 mg of codeine. Because of the possibilities of nausea and addiction, codeine should be used only if absolutely necessary. Then it is ordered in 60 mg doses every 4 hours with salicylates. At the optimum time for healing, callus formation should be seen on the radiograph. However, the surgeon should be guided by clinical signs of union in determining the length of time immobilization is necessary, since bone healing in the form of secondary callus takes place sometimes before it is demonstrable clearly on the radiograph. The intermaxillary elastics or wires are removed, and the fracture is tested gently with the fingers. If clinical movement occurs, the elastics should be replaced for another week. Reexamination is carried out at weekly intervals until healing has occurred. Even with the best of treatment, some fractures will take several months to heal. In instances in which an unusual delay has occurred, a cast cap splint can be cemented over the fractured member so that the jaws can be opened. Function stimulates healing at this stage. If nonunion is inevitable, all fixation is removed, and the patient is allowed to rest for several months so that the bone ends may round off preparatory to a bone graft. It is not an isolated occurrence to find that the patient has bony union when he returns after moderate functional use of the jaw during the interim. After removal of the elastics the patient is seen daily for 3 days. If the occlusion and the fracture site remain satisfactory, the wiring or arch bars can be removed at that time. The patient should eat a soft diet for a week, until muscle and joint function have returned. Scaling and polishing of the teeth should be done, and minor occlusion disharmonies should be corrected by grinding. Complications Delayed healing in the properly reduced fracture occurs in the presence of inadequate or loosened fixation, infection, or a fault in the vital reparative effort. Loosened fixation usually is associated with poorly placed wires. Wires that have not been placed under the cingulum in anterior teeth or those that have not been tightened properly so that they stay under the cingulum will not hold. The multiple-loop wiring technique fails if the strand of wire bridging an edentulous area is not twisted so that it fits the space exactly. For that reason the eyelet wire for double teeth or a thin wire wound twice around a single tooth is preferable in areas of missing teeth. Arch bars should be wired to every tooth in the arch. The occasional patient who removes his elastics for a small chicken dinner should be strongly advised of the serious consequences. He should be warned that a bone graft is an interesting operation for the oral surgeon and that the patient himself will request such an operation when he tires of a flopping jaw. Infection caused by bizarre and resistant organisms is becoming more frequent. A routine blood culture and organism sensitivity test should be done in all cases of postoperative infection. If pus forms, it should be cultured. Systemic and metabolic disease will cause delayed healing. In some instances the cause for dealyed healing is not apparent even after a general medical survey, and healing takes months instead of weeks. Nonunion is an aftermath of delayed healing if the cause is not corrected. A bone graft is necessary. Sometimes freshening of the area through open reduction is sufficient. A 36 technique for an intraoral approach, freshening, and the placing of homogenous bone chips has been successful. Malunion is healing in poor position. Poor treatment, an intercurrent accident, or a lack of treatment is responsible. The bone must be refractured and immobilized. However, there is a fine line in judging whether the degree of malposition requires treatment. If the clinical position is satisfactory and the radiograph reveals a small amount of malposition, no treatment may be necessary. Repositioning in this instance is called "treating the x-ray". If facial contours and esthetics are involved as a result of malunion, cartilage or bone onlays have been used successfully. Fractures of the Maxilla Maxillary fractures are serious injuries because they involve important adjacent structures. The nasal cavity, the maxillary antrum, the orbit, and the brain may be involved primarily by trauma or secondarily by infection. Cranial nerves, major blood vessels, abundantly vascular areas, thin bony walls, multiple muscular attachments, and specialized epithelia characterize this region in which injury can have disastrous consequences. Causes Automobile injuries, blows, industrial accidents, and falls can cause such injuries. Rapid deceleration in a fast-moving vehicle can produce a typical middle face fracture known as a "dashboard injury". The force, direction, and location of the blod determine the extent of the fracture. In the District of Columbia General Hospital survey, maxillary fractures represented 6% of all jaw fractures. Classification - signs and symptoms Horizontal fracture The horizontal fracture (Le Fort I) is one in which the body of the maxilla is separated from the base of the skull above the level of the palate and below the attachment of the zygomatic process. The horizontal fracture results in a freely movable upper jaw. It has been called a "floating jaw". An accessory fracture in the midline of the palate may be present, which is represented by a line of ecchymosis. The maxillary fracture can be unilateral, in which case it must be differentiated from an alveolar fracture. The alveolar fracture does not extend to the midline of the palate. Displacement is dependent on several factors. The force of a severe head-on blow may push the maxilla backward. Muscular pull may do the same. In a low-level fracture, muscular displacement is not a factor. If the fracture is at a higher level, the pterygoid muscle attachments are included in the loose fragment, which is consequently retruded and depressed at the posterior end, resulting in an anterior open bite. Some fractures are depressed all along the line of separation. Many horizontal maxillary fractures are not displaced, and therefore the diagnosis is missed at first examination. Evidences of trauma may be seen on the teeth, lips, and cheeks. Unless they are severely traumatized, the anterior teeth should be grasped between thumb and forefinger and a forward-backward motion made. The molar teeth on first one side and then the other should be similarly moved. A fractured jaw will move. The distally impacted jaw will not move, but 37