A practical treatise on fractures and dislocations of the jaws for students and practitioners

Front matter

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CHAPTER I—Dislocation of the Jaws

duced and Congenital Dislocations.

CHAPTER I]—Fractures of the Jaws. .

Definitions; Etiology; Influence ie Ace Bex and ea oncne. Bre:

disposing Causes; Determining or Exciting Causes.

Classes and Types.

CHAPTER IV—Signs and Symptoms of Fracture. .

aS

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Objective Signs: Deformity, Abnormal Mobile, nilocelasten:

Crepitus, Edema.

Subjective Symptoms: Pain, Loss of Function, History.

CHAPTER V—Diagnosis. . eee The X-ray in icp andl cect

CHAPTER VI—The Process of Repair. .

Re-establishing Normal @ adinone: Conmicane Oona Buncione of Compact and Cancellous Bone.

CHAPTER VII—Complications in the Process of Repair. .

General Complications.

CHAPTER VIII—Prognosis ......

Influences that Affect Boece es Alcoholism, Disease, Infection, Location.

CHAPTER [X—Treatment.

Reduction, Retention: Picventon Control. Muscle Strain. Bandaging. Interdental Ligation. Methods of Military Surgeons. Splints. Headgear. Correction of Lateral Displacement.

CHAPTER X—Gunshot Fractures. .

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. 54 oe ie OIL

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Formulary of Dr. George B. Hayes: The Lodge Cast Tin Jacket.

War Surgery: at Neuilly, France. Method of Dr. George L. Villian. Growth of Bone.

CHAPTER XI—Treatment by Bone Grafts. .

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History. Fundamental Principles. Albee’s “Method. %Gallie ead

Robertson. Technic.

CHAPTER XII—Anesthesia in the Reduction of Fractures..................

Local Preferable. Conductive or Nerve Blocking. Intra- and Extra-Oral. Instrumentarium and Technic. Cautions.

Preface

This little work has been written in the endeavor to meet the demand of medical and dental students and of the physician and the dentist for something concise, simple, practical and modern on Fractures and Dislocations of the Jaws. It was in the hope of presenting a practical treatise on this subject that the work was undertaken. It is the result of experience gained in twenty years of practice and twelve years as a teacher of oral surgery.

It has been the aim throughout the book to present nothing that does not have practical value. Nearly all of the methods of treatment that are presented, or modifications of them, have been used by the author from time to time in his practice or in the University Hospital Clinics. .

An attempt has been made to give proper credit to those who previously have recorded their ideas. If it appears that proper credit has not been given, it is because the author has incorporated ideas which he has acquired and approved from sources that are so varied that they can not at this time be traced. It has been the aim to bring together in one place the many valuable suggestions on, and methods of treatment of, Fractures and Dislocations of the Jaws.

The author is deeply indebted to Dr. George B. Hayes, Neuilly, (Paris), France, for his permission to review and incorporate in this little work some of bis most brilliant achievements in War Dental Surgery, without which this work would be incomplete; to Dr. James G. Van Zwaluwenburg, of Ann Arbor, Michigan, for his contribution on the “‘Use of the X-ray in Diagnosis;’’ to Drs. Gallie and Robertson, of Toronto, Ontario, for the privilege of incorporating their ideas on bone -grafts; to Dr. Don M. Graham, of Detroit, Michigan, for valuable illustrations on interdental ligation; to Major Joseph D. Eby, of Atlanta, Georgia, for his contribution on war fractures; to Captain E. Ballard Lodge, of Cleveland, Ohio, for his method of casting splints in block tin, and to the publishers for their many courtesies shown in the preparation of this little work.

CHALMERS J. LYONS Ann Arbor, Michigan, May, 1919.

In looking over the literature relating to the practice of medicine and surgery, we find that the oldest documents which are in existence at the present time are the various treatises contained in the collection which bears the name of Hippocrates.

Hippocrates (460-367 B.C.), the celebrated Greek physician, discusses at some length fractures and dislocations of the jaws. Many of his arguments in the treatment of these classes of human ills are of such excellence that it always has been a question which has excited curiosity, by what steps the treatment had attained to such perfection at so early a period.

Indeed, the principles laid down by Hippocrates in this work over two thousand years ago are so sane that many of them can be followed successfully today. His extensive practice and, no doubt, his great familiarity with the accidents occurring at the public games of his country, furnished him with ample opportunities for becoming acquainted with fractures and dislocations as his treatises on this subject abundantly testify. In fact, until within comparatively recent years, the plan of treatment of such cases was not at all to be compared with his skillful mode of adjusting fractured bones and of securing them by means of waxed bandages. Not only was Hippocrates skillful in the treatment of these conditions, but his methods were based on a knowledge of anatomy that seems almost incredible when we consider the state of knowledge of the people twenty-four centuries ago.

The writer believes that it will be of some interest in the history of fractures and dislocations to insert here abstracts of some of the early teachings of the great Greek physician.

He says in part: ‘‘The jaw bone, in few cases, is completely dislocated, for the zygomatic process formed from the upper jaw bone (malar?) and the bone behind the ear (temporal?) shuts up the heads of the under jaw, being above this one (condyloid process’). Of these extremities of the lower jaw, the one from its length, is not much exposed to accidents, while the other (the coronoid?) is more prominent than the zygoma, and from both these heads nérvous tendons (ligaments?) arise, with which the muscles called temporal and masseter are connected; they have these names from their action and connections, for in eating, speaking and the other functional uses of the mouth, the upper jaw is at rest, as being connected with the head by synarthrosis, and not by diathrosis; but the lower jaw has motion, for it is connected with the upper jaw and the head by enarthrosis. Wherefore, in convulsions and tetanus the first symptom manifested is rigidity of the lower jaw. These are the reasons why complete dislocation

1 INTRODUCTION does not readily take place; and this is another reason, because there is seldom a necessity for swallowing-so large pieces of food as would make a man gape more than he easily can open his mouth, and dislocation cannot take place in any other positions than in great gaping, by which the jaw is displaced to either side.

“This circumstance, however, contributes to dislocation, Hien: of nerves (here Hippocrates probably means ligaments), and muscles around joints or connected with joints, such as frequently are moved in using the member, are the most yielding to extension, in the same manner as well-dressed hides yield the most. With regard, then, to the matter in hand, the jaw bone rarely is dislocated, but frequently is slackened (partially displaced) in gaping, in the same manner as many other derangements of muscles and tendons arise.’’!

While the language Hippocrates uses in his descriptions is not as concise and coherent as it might be, yet when we consider the time and conditions under which it was written we must refrain from making any criticisms. His description of the symptoms of dislocation of the jaw is worthy of more modern ages:

“Dislocation is particularly recognized by these symptoms: the lower jaw protrudes forward, there is displacement to the opposite side, the coronoid process appears more prominent than natural on the upper jaw, and the patient cannot shut his lower jaw but with difficulty. The mode of reduction which will apply in such cases is obvious: one person must secure the patient’s head and another taking hold of the lower jaw with his fingers within and. without at the chin, while the patient gapes as much as he can, first moves the lower jaw about for a: time, pushing it to this side and that with the hand, and directing the patient himself to relax the jaw, to move it about, and yield as much as possible; then all of a sudden the operator must open the mouth while he attends at the same time to three positions: Fvrst, the lower jaw is to be moved from the place to which it is dislocated to its natural position; second, it is to be pushed backwards, and third, along with these the jaws are to be brought together and kept shut. This is the method of reduction, and it cannot be performed in any other way.”

This last statement is dogmatic, but stated in Hippocrates’ time, it can be overlooked, for he was the only person at that time who could speak upon any subject in medicine with any degree of authority.

Further he says: “‘A short treatment suffices; a waxed compress is to be laid on and bound with a loose bandage. It is safer to operate with the patient laid on his back and his head supported on a leather cushion well filled, so that it may yield as little as possible; but some person must hold the patient’s head.

‘Galen, in his Commentary on the passage, explains it as applying to displacement of the muscles. It would seem to be the species of incomplete displacement described by Sir Astley Cooper.

‘INTRODUCTION _ 13

‘‘When the jaw is dislocated on‘ both sides, the treatment is the same. The patient is less able to shut.the mouth than in the former variety, and the jaw protrudes farther in this case, but is not distorted; the absence of distortion may be recognized by comparing the corresponding rows of the teeth in the upper and lower jaws. In such cases reduction must be performed as quickly as possible. The method of reduction has been described above.

“‘Tf not reduced, the patient’s life will be in danger from continual fevers, coma attended with stupor (for these muscles when distorted and stretched preternaturally induce coma), and there usually is diarrhoea attended with bilious, unmixed and scanty dejections; and the vomitings, if any, consist of pure bile, and the patients commonly die on the tenth day.”’

So thorough was Hippocrates’ daccnatione of dislocation of the lower jaw that it was copied by all: the subsequent authorities in ancient times.

His discussions on “‘Fractures of the Jaws’’ are equally interesting. Many of these he describes as occurring among the ancient athletes and gladiators. From his description it can be seen that he had large experience in the treatment of fractures of all kinds, and his observations and findings are worthy of reproduction here:

“In fracture of the lower jaw, when the bone is not fairly broken across and is still partially retained but displaced, it should be adjusted by introducing the finger at the side of the tongue and making suitable counterpressure on the outside; and if the teeth at the wound be distorted and loosened, when the bone is adjusted, they should be connected together, not only two but more of them, with a gold thread if possible, but otherwise with a linen thread, until the bone is consolidated; and then the part is to be dressed with cerate, a few compresses and a few bandages, which should not be very tight, but rather loose. For it should be well known that in fracture of the jaw, dressing with ~ bandages if properly performed is of little advantage, but occasions great mischief if improperly done. Frequent examinations should be made about the tongue and prolonged pressure should be applied with the fingers in order to rectify the displaced bone.”

“‘But if the bone is fairly broken across it is to be set in the manner now described. When adjusted the teeth are to be fastened together as formerly described, for this will contribute much towards keeping the parts at rest, especially if properly fastened, and the ends of the threads secured with knots. But it is not easy to describe exactly in ‘writing the whole manipulation of the case; but the reader must figure the thing to himself from the description given. Then one must take a piece of Carthaginian leather; if the patient be a younger person it

~ 2Galen, in his Commentary, explains that our author means all this is to be done by the patient and not by the physician.

14 INTRODUCTION

— will be sufficient to use the outer skin, but if an adult, the whole thickness of the hide will be required. It is to be cut to the breadth of about three inches, or as much as will be required, and having smeared the jaw with a little gum (for thus it sticks more pleasantly), the end of the skin is to be fastened with glue near the fractured part of the jaw ata distance of an inch or a little more from the wound. This piece is to be applied below the jaw; but the thong should have a cut in it, in the direction of the chin, so that it may go over the sharp point of the chin. Another piece of thong like this or somewhat broader is to be glued to the upper part of the jaw at about the same distance from the wound as the other thong; this thong should be so cut as to encircle the ear. The thongs should be sharp-pointed at the part where they unite, and in gluing them the flesh of the thong should be turned to the patient’s skin, for in this way it will be more tenacious. Then we must stretch this thong, but still more so the one at the chin, in order to prevent the fragments of the jaw from riding over each other, and the thongs are to be fastened at the vertex and then a bandage is to be bound round the

Fig. 1 forehead (Fig. 1) and a proper apparatus is to be put over all to prevent the bandages from being displaced. The patient should lie upon the sound side of the jaw, not resting upon the jaw but upon the head. He is to be kept on a spare diet for ten days and then nourished without delay. If there be no inflammation during the first days, the jaw is consolidated in twenty days, for callus quickly forms in this as in all the other porous bones, providing there be no sphacelus (exfoliations). Those physicians. who have not judgment combined with dexterity, expose themselves in fractures of the jaws as in other cases, for they apply a variety of bandages to a jaw bone, sometimes properly and sometimes improperly. For all such bandaging of a fractured jaw bone

INTRODUCTION 15 has a tendency rather to derange the bones connected with the fracture than to bring them into their natural positions.

“But if the lower jaw be disjointed at its symphysis, it is the work which anyone can perform to rectify it; for the part which protrudes is to be pushed inwards by pressure with the fingers and the part which inclines inwards is to be forced outwards by pushing with the fingers from within. It is after having applied extension to separate the fragments that this is to be done, for thus they will be more easily restored to their natural position than if one should bring them together by using force. This is proper to be known as applying to all such cases. When you have set the parts, you must fasten the teeth on both sides to one another as formerly directed. The treatment is to be accomplished with cerate, a few compresses and bandages. This part in particular requires a short but complex bandaging, for it is nearly cylindrical, though not exactly so. (Figs. 2 and 3.)

“If matters be properly adjusted and the patient kept quiet there -will be speedy recovery and the teeth will be uninjured; but if not the recovery will be more protracted; the teeth will be distorted, will give trouble and become useless.”

From Hippocrates’ writings we can see that he had an extensive knowledge of the subject of fractures. His thoughts on bandaging alone are invaluable, and today if the same careful attention were given to bandaging the jaws in case of fracture, the indifferent results in many cases would not exist, but normal conditions would be more nearly established.

Hippocrates was followed by a great number of others, some of whom were much interested in fractures of the jaws.

Aurelius Cornelius Celsus, a celebrated Roman physician and writer who lived about 25 A.D., in his writings, ‘‘De Medicina,” states: ‘‘In the fractures of the other bones we frequently find one fragment

16 ee tins INTRODUCTION detached from ‘the other; in the mandible the fragments, although thrown out of place, always adhere one to another. Consequently, in this fracture we must first of all replace the fragments to their normal position, passing from the inside of the mouth and from the outside with the forefinger and thumb of both hands. Then in case of a transverse fracture (in which case an unevenness in the level of the teeth is produced), it is necessary, after having set the fragments in place, to tie together the two teeth nearest to the fracture with a silk thread (corresponding to our wiring today), or else, if these ate loose, the next ones. After this one should apply externally to the part corresponding to the lesion a thick compress, dipped in wine and oil and sprinkled with flour and powdered olibanium. -The compress is to be fixed in place by means of a bandage or a strip of soft leather with a longitudinal slit in the middle S embrace the chin, the two ends being tied together above the head.”

Galen’s Cannes: is the neat of the Areca oe on fractures, and in fractures and dislocations of the jaws he reiterates and comments on much of Hippocrates’ writings.

Avenzoar, a renowned Arabian physician, about the beginning of the twelfth century, in his writings, a compendium of practice “ Al- Teisir,’’ describes bandages for the fixation of the mandible. Apparently he depended entirely upon bandages to retain the fragments in position.

About this time a text-book of surgery was compiled and it is interesting to note some of the methods of treating fractures of the jaws. In this compilation we find the following on the treatment of fractures: ‘‘Take olibanium, mastic, colophen, glue, dragon blood; _all this must be mixed with liquified resin and become ointment, which is placed over until complete consolidation, and everything must be fixed with the little lances in order that the portions be prevented from moving out of place. In the fracture of the mandible if the lower teeth are not in contact with the upper ones, the patient cannot masticate. Then the patient must be taken by the lower maxille and the parts moved here and there until the lower teeth will touch the upper ones.”’

In 1275 A.D., Wilhelm from Saliceto wrote the ‘‘Proxeos Totius Medicine,’’ in which he speaks of the fractures of the jaws. In this he suggests a modification of the primitive methods of ligating the teeth. He suggests not only ligating and binding the teeth proximal to the fracture not only between themselves but also to the corresponding teeth of the maxille.

Ambroise Paré, ‘‘ The Father of French Surgery,’’ 1517-1590, wrote considerable on fractures and dislocations of the jaw. He says: “‘Then will be applied a leather ferrule such as from which the soles of a boot are made, which has been divided in the middle at the level of the chin, long and wide as the mandible. And then will be made a ligature two fingers wide and as long as necessary, cut at the ends, having only one

INTRODUCTION re finger wide, and at the level of the chin it will be parallelly cut, for the purpose of embracing and pressing better over the chin; and at the four extremities the shorter will be sewed at the top of the head to a night cap or calotte, and the other two longer ends will be kept transversely and sewed behind the same cap, everything done as skillfully as possible in order to hold well the fracture.”’

Bunon (1743), in his treatise on the diseases of the teeth, mentions two cases of fractures of the jaws which he succeeded in curing in a short time by the method of binding the teeth, the preceding attempts of experienced surgeons having failed entirely. One of these cases is particularly interesting. The seat of fracture corresponded with the bicuspid which, however, had become dislodged from the effect of the wound; the neighboring teeth also were loosened. Bunon filled the empty space left by the bicuspids with a piece of ivory provided with two holes; then by an ingenious crossing of threads passing from the second molar on one side to the second bicuspid on the other, very tightly tied, he formed one single block and succeeded in bringing about consolidation of the loosened teeth and the complete cure of the fracture, which was effected in less than a month. (Guerini from Brophy.)

The foregoing is given merely as a preface to the following chapters on. fractures and dislocations of the jaws to show that long before the Christian Era considerable thought was given to this subject. The development of the treatment of fractures of the jaw has hardly kept pace with the treatment of fractures of other parts of the body, probably on account of comparative scarcity of the number of cases, but modern machinery and modern methods of travel are adding yearly to the increasing number of cases of fracture and dislocation of the jaws.

The greatest factor of all times in producing fractures of the jaws was the great European War. It is reported that in one hospital alone in Germany more than five hundred cases of fracture of the jaws were being treated at one time. New methods and new appliances were introduced in the treatment of these war cases that have placed the treatment of fractures and dislocations on an entirely new basis.

Chapter I

Dislocation of the Jaws* articular portions of the bones entering into the formation of a

joint. While dislocations of the lower jaw are not rare, yet these dislocations are not as common as are dislocations in other parts of the body.

1Stimpson states that ‘“‘compared with other surgical injuries, dislocations (in general) are infrequent; the proportion to fractures is about one to ten.’’ In a compilation of fifteen hundred and twenty-seven dislocations, he found sixty-one dislocations of the lower jaw.

Two principal classifications may be made of dislocations of the lower jaw viz., bilateral and unilateral. Of these the bilateral is the more common, the proportion being about five to two, according to Malgaigne.

These again may be classified as:

1. Simple, one in which the joint is not penetrated by a wound.

2. Compound, one in which the contiguous tissue is torn to the outer surface and the wound is in communication with the outside air.

3. Complete, one in which the articular surfaces are completely separated.

4. Complicated, one which is associated with other injuries, such as fracture.

5. Habitual, one which frequently occurs after reduction.

6. Recent, one in which there is no complicating inflammation.

7. Pathologic or spontaneous, one which results from disease.

8. Traumatic, one due to an injury or to violence.

ETIOLOGY

In order to understand the etiology of dislocations of the lower jaw, a knowledge of the comprehensive mechanism of the temporomandibular articulation and the normal movement of the mandible should be acquired.

7In the temporomandibular articulation, the socket is formed partly by the mandibular fossa and partly by the articular eminence, and over the latter an approximately congruent surface for the head of the condyle is formed by the articular disk. The two temporomandibular articulations act simultaneously. When the mouth is opened, the head

*As the subject of dislocations of the jaws is one that must necessarily be brief when compared with that of fractures of the jaws, it is deemed best by the author to reverse the usual order in which these subjects are generally. presented, and will discuss dislocations first before taking up the more important subject of fractures.

1Stimpson’s “Fractures and Dislocations.”

tSabotta and McMunich Human Anatomy.

\ DISLOCATION is defined as an abnormal displacement of the

DISLOCATION OF THE JAWS 19 of the condyle, with the inter-articular disk, glides forward on the articular eminence, and when the mouth is closed it slips back into the mandibular fossa. The opening and closing of the mouth are consequently attended by a sliding of the mandible (a sliding joint).

In addition to this modified form of hinge movement, the articulation possesses a second kind of motion, viz., the lateral displacement of the mandible in reference to the skull. In this movement, one condyloid head remains in the mandibular fossa and rotates on pivots on the center, (the rotation being accomplished by the action of the plerygoideus internus muscle), while the other advances on the articular eminence, a movement which is impossible when the mouth is opened

Fig. 4 to its greatest extent. Both the hinge and the lateral movements are combined in the act of mastication.

The movements of the jaw are limited by the capsular ligament. The anterior portion of the capsular ligament is not strong and usually is-ruptured in dislocations of the jaw.

Dislocations of the lower jaw usually occur when the mouth is open and when the heads of the condyles are forward on the articular eminence. The head of the condyle then may pass over the articular eminence on one or both sides. (F7g. 4.) If on one side a unilateral dislocation is constituted, and if both condyles pass over the articular eminence a bilateral dislocation results. The contraction of the masseter and temporal muscles draws the condyles up against the inferior surface of the zygoma, where it becomes locked. Backward dislocation cannot occur without fracture of the tympanic portion of the temporal bone.

Backward dislocations are caused by great violence received upon the chin from before backward. One or both heads of the condyle may be driven through the tympanic plate into the external auditory canal. This may occur quite easily if the mouth is held partly open when the

20 DISLOCATION OF THE JAWS blow occurs, or in an edentulous jaw when there is no support given it by opposing teeth.

The symptoms are pain and hemorrhage from the ear, immobility of the lower jaw. and displacement backward.

~The author, in 1914, had acase of this type where the backward displacement was the distance of 1 cm. The patient was working in a railway machine shop and was struck on the chin by a flying piece of iron. The lower jaw also was fractured at the symphysis.

A few cases of upward and outward dislocations have been reported by LeFevre, Roberts, Neis and others, but this type of dislocation is very rare.

By far the most common type of dislocation is forward. Any pathologic changes in the glenoid fossa which would result in a condition that would reduce the depth of articulation would predispose to dislocation of the jaw.

The direct causes arise in active muscular contraction during forced opening of the mouth, such as yawning, laughing, vomiting, epileptic attacks, inserting mouth gags for operations in or around the mouth, extraction of teeth, etc.

The indirect causes follow from some form of violence directed to the anterior portion of the lower jaw when the mouth is open, which forces the angles of the jaws backward and the condyles forward, the axis of motion being in the region of the bicuspid teeth. This may be a kick from a horse, a blow from a fist, a fall, or any other form of violence at the point named.

A blow on the side and posterior portion of the mandible may be sufficient to cause unilateral dislocation.

SYMPTOMS

In bilateral dislocations (Fig. 5) the mouth is held open—the patient can open the mouth wider but is unable to close it. Palpation will indicate that the condyles are out of their normal position. The patient will be in considerable pain, such as is felt in cramps, this being due to the contraction of the masseter and temporal muscles. Excitation of the parotid gland due to the spasmodic contraction of the muscles will cause a profuse flowing of saliva. Deglutition and talking will be difficult.

In unilateral dislocation (Fig. 6) of the lower jaw, the jaw will be drawn to one side and the mouth partly open. Palpation will indicate the head of the condyle on one side in front of the articular eminence. A prominence may be seen on the side of the face at this point. There will be considerable pain in an attempt to move the jaw. As in bilateral dislocation, there will be profuse flowing of saliva and deglutition will be attempted with difficulty. The X-ray may be used to determine the character of the dislocation and amount of injury to the contiguous osseous structures.

DISLOCATION OF THE JAWS 21

TREATMENT

The immediate reduction of a dislocation is very desirable to successful treatment. This usually can be accomplished by pressing downward and backward on the posterior portion of the mandible with the thumb, which should be padded with gauze for protection against the teeth, and at the same time elevating the anterior portion with the fingers. This usually will force the heads of the condyles back over the eminentia articularis into the glenoid fossa.

a) Another method is to place a small block of wood, such as a pencil, between the molar teeth as a fulcrum and force the chin upward and backward with the fingers.

In some obstinate cases an anesthetic may be resorted to in order to relax muscular tension. A few cases have been reported where the coronoid processes of the mandible have become engaged under the malar process and prevented reduction. These cases are extremely rare and hardly can be taken into account in the treatment of dislocations. Usually the head of the coronoid process rests against the inferior surface of the malar process and prevents closure of the mouth.