FRACTURES OF THE BODY OF THE MANDIBLE

FRACTURES WITHOUT DISPLACEMENT

If the patient’s upper and lower teeth oppose one another, so that he bites normally, there is no displacement. Provided he is cooperative, there is no need to wire his fracture, although it is better practice to do so.

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 his chin, his face, and his forehead. If you use a crepe bandage, rewrap it every day to maintain tension.

CAUTION! A bandage can be detrimental if you apply it in a displaced fracture.

If a patient is uncooperative, he may remove his bandage, so you had better wire his fracture.

FRACTURES WITH DISPLACEMENT BUT NO TISSUE LOSS

If the fracture lies within the tooth bearing area, you have two choices.

(1) If the patient is cooperative, unlikely to take the wires off, and has plenty of teeth, use interdental eyelet wiring.

(2) If he is uncooperative, if he has few teeth, or if there is gross displacement, use arch bars or Risdon wiring.

If the fracture lies outside the tooth bearing area, use interosseous wiring combined with interdental wiring, or arch bars or Risdon wiring on the same criteria as (1) and (2) above.

If he has no teeth, refer him. If you cannot refer him, do your best with interosseous wiring.

If you have no suitable wire, do your best with a head bandage, as in Fig. 62-17.

If possible, operate during the first 24 hours, but if oedema is severe, you can wait up to a week to let it subside. If you are in any doubt about the patient’s general condition, wait.

FRACTURES WITH SEVERE TISSUE LOSS

Usually, there is severe displacement also. Toilet the patient’s wound, replace the bone and soft tissues as best you can, and fix the remains of his mandible to his maxilla by any suitable method. Close his wound, suture his skin to his mucous membrane, and refer him.

INTERDENTAL EYELET WIRING FOR MANDIBULAR FRACTURES

INDICATIONS Displaced fractures of the mandible with: (1) a sound maxillary arch, and (2) enough teeth opposite one another to take the wire.

CONTRAINDICATIONS If a patient is drunk and there is any danger of vomiting, don’t wire his teeth until his stomach is empty.

ANAESTHESIA FOR EYELET WIRING OR ARCH BARS See above. There are several possibilities. (1) If displacement 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, if necessary on both sides. Supplement these where required, by infiltrating the mucosa round his teeth (A 6.3). Alternatively, use infiltration anaesthesia only. If you are using 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 his nose (A 13.4). (3) Ketamine can be used.

CAUTION! Pass a nasogastric tube and aspirate his stomach before inducing him.

WORKING WITH WIRE Use soft 0.35 mm stainless steel wire, or any convenient soft wire. Stretch it before you use it, or it will become slack, but don’t over-stretch it, or it will 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. Keep 20 of them ready in a box in the theatre.

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, protect the patient’s eyes, because a loose end can spring back and injure them. (1) Close them, and cover them with vaseline 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.

INSERTING THE EYELETS Look carefully at the facets on the patient’s teeth and study the way his jaws fit together. If there is any abnormality in the way they occlude, allow for it when you immobilize the fragments.

Push an eyelet well down between two teeth (1) as shown in C, Fig. 62-17, bring the ends of the wire back between two adjacent teeth (2), pass one end of the wire through the eye (3), twist both ends together, pulling tightly as you do so, and cut them off (4). Tuck the sharp ends between his teeth. Pull on the eye to bring it nearer to the occlusal surface and make sure it is secure.

Fix about five eyelets in either jaw in suitable places, so that when they are joined by tie wires, these will run diagonally in both directions and brace his jaws together. Don’t place the eyelets immediately above one another, or you will not 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 many casualties, but the wires loosen more easily.

REDUCING A FRACTURED MANDIBLE If there are any loose teeth in the fracture line, this is the time to remove them. Bleeding sockets will not now obscure the wiring.

CAUTION! (1) Control bleeding. (2) If you have intubated the patient and his throat is packed, remove the pack before you 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 the patient’s teeth fit together properly, the fragments will be aligned. Place the tie wires loosely at first, and only tighten them after you have checked the occlusion. Tighten them little by little, first in the molar area on one side, then in the molar area on the other side, working round towards the incisors as you do so.

CAUTION! (1) If you tighten the wires firmly on one side only first, you will cause a crossover bite. (2) If you tighten the incisor wires first, you will cause a posterior open bite. (3) Don’t twist the wire too tightly on a single rooted tooth, or you may pull it out. You can exert more tension on a multi–rooted one. (4) Make sure that you have not trapped his tongue.

Finally, run your finger round his mouth to make sure that there are no loose wires which might injure his lips. Coat his lips and the inner surfaces of his cheeks with vaseline.

ALTERNATIVE METHOD OF EYELET WIRING USING HOOKS AND RUBBER BANDS

This is shown in D, Fig. 62-17. Use it when there is any danger of vomiting, or if a patient has to travel. You will need thicker wire than with eyelet wiring.

Surround the neck of every second or third tooth with a loop of wire. Leave the two ends free towards the lips. Twist them a few times and then make a small hook with the free ends. Make sure they really are smooth.

Pass short rubber bands diagonally over these wire hooks. If necessary, cut them from a suitable size of rubber tube as in B, in this figure.

RISDON WIRING FOR A FRACTURED MANDIBLE

INDICATIONS As an alternative to an arch bar for a fracture of the mandible that needs fixation. Some surgeons prefer a Risdon wire to an arch bar.

METHOD Take two pieces of soft 1 mm stainless steel wire about 25 cm long. In the middle of each piece twist a loop that will fit over one of the posterior teeth of the patient’s broken lower jaw. Fit the loops over these teeth, and twist them secure. Then twist the ends of each wire double. Bring the twisted strands from each side together, reducing the fracture as you do so. Twist them together in the midline, so that they lie along the necks of the teeth. Cut the joined 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.

FITTING ARCH BARS FOR MANDIBULAR FRACTURES

This is not as easy as it looks! Use a pair of heavy cutting pliers to cut the bars to the right length for each jaw; try to make them span as many teeth as possible; and leave them long enough for the end to be bent towards the posterior surface of the last available tooth. Bend them to shape along the necks of the teeth with the hooks facing towards one another. The patient’s lower jaw will be displaced, so shape the arch bar for it to fit round his upper jaw, or fit it round the lower jaw of another person with the same size of arch.

Use 15 cm lengths of 0.35 mm wire to wire the arch bar to the teeth. It is usually best to start in the premolar region by wiring one tooth on each side. Pass the wires round the necks of the teeth and wire as many as you can. Because of their shape, incisor teeth are usually difficult to wire, so you may have to leave them. If the wire tends to slip off, be prepared to raise the gum with a periosteal elevator. Tuck the ends of the wires aside where they will not injure the lips. Fix the arch bars with rubber bands.

AN IMPROVISED ARCH BAR Take some paper clips, open them, twist them together, make side hooks on them, point these upwards on the top teeth, and downwards on the bottom ones. Fix this improvised arch bar to the teeth with ordinary stainless steel wire, and pass rubber bands between the hooks.

LOWER BORDER INTEROSSEOUS WIRING FOR MANDIBULAR FRACTURES

INDICATIONS (1) Control of the posterior fragment when this has no teeth. (2) Control of both fragments when the patient has no teeth or insufficient teeth for interdental wiring. You will usually need interdental wiring or an arch bar also.

CONTRAINDICATIONS (1) Established infection of the fracture site. (2) Children in whom unerupted teeth may be injured.

ANAESTHESIA Endotracheal anaesthesia is essential (A 13.2).

METHOD Make a 3 cm incision over the fracture site in line with the patient’s facial nerve, as in A, Fig. 62-20. The exact site of the incision will depend on where his fracture is. Reflect the skin. Under the incision you will find the superficial fascia and the platysma muscle.

Cut across the fibres of his platysma, and use blunt dissection 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 masseter. 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 anterior edge of his masseter. If so, retract the vessels anteriorly.

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 patient’s mandible (C), and separate It from the deep tissues 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 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 patient’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 this eye through the hole in the other fragment of his mandible from the buccal to the lingual side. Thread the deep end of the first wire through the loop and twist it round itself (E). Use it to pull the second wire through the first hole. Remove the ’eye’ wire and twist the two ends of the first wire gently together to reduce the fracture until there is only a hair–line crack (F).

When you have secured the fracture (G), cut the twisted ends of the wire off short and tuck the cut end into one of the holes, so that it doesn’t stick out into the soft tissues (H). Cut a very fine strip of rubber glove and insert this as a drain.

Close the wound in layers and bandage it with a light pressure bandage. Remove the drain after 24 hours.

UPPER BORDER INTEROSSEOUS WIRING FOR MANDIBULAR FRACTURES

INDICATIONS This is seldom necessary. In bilateral fractures insert an upper border wire to prevent the muscles pulling the anterior fragment downwards, and making the fracture line gape.

METHOD Wire the upper border before the lower one. Make an incision along the crest of the alveolus inside the patient’s mouth. Drill small holes on either side of the fracture line, pass a piece of soft stainless steel wire through it, reduce the fragments, and twist the ends of the wire tight. Cut the ends short and tuck them into the nearest drill hole. Close the incision very carefully, because infection is common.

POSTOPERATIVE CARE FOR MANDIBULAR FRACTURES

Don’t remove the patient’s tracheal tube until anaesthesia is really light. If you have wired his teeth under general anaesthesia, 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 consider this is unnecessary. Lie the patient on his side and have a sucker ready, with a tube attached which you can pass down his nasopharyngeal tube.

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 nurse, in charge. Be sure that the nurses know how to remove the wire, if he wants to vomit. Tell, them to cut the closing wires, not the eyelets. Later, he will be more comfortable if you nurse him sitting up.

POST REDUCTION X–RAYS If these are not satisfactory, correct the malposition as soon as possible.

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 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.

Careful oral hygiene Is essential to prevent osteomyelitis. Ask him to clean his teeth with a tooth-brush after every meal. Or, irrigate his mouth with saline or 0.5% chlorhexidine from a Higginson’s syringe.

FOLLOW–UP FOR A MANDIBULAR FRACTURE If you send a patient home wired, tell him to keep a pair of pliers available, so that he can remove the wire if necessary. Ask 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 firm, clean the patient’s mouth and remove the eyelet wires. Leave interosseous wire in place unless it becomes infected.

DIFFICULTIES WITH MANDIBULAR FRACTURES

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.

If his JAW HAS FAILED TO UNITE, encourage him to accept his disability. Non–union is rare. It may follow infection, or be the result of leaving a tooth in the fracture line.

If his MANDIBLE HAS BECOME INFECTED, give him antibiotics (2.7), clean up his jaw as much as possible, remove 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 are kept moving, of if you try to wire one which is already infected. Prevent it by always giving prophylactic antibiotics whenever the mucoperiosteum is torn.

If his LOWER LIP IS NUMB, it will probably recover. Warn him of the danger of burning his lower lip with hot drinks or cigarettes.

If his TEETH DO NOT MEET when the fixation is removed, his malocclusion will probably correct itself if it is mild. If it is more severe, his cusps can be ground away. If it is gross, refer him for refracture of his mandible, or the removal of selected teeth. If he adopts a bite of convenience across a partly healed fracture, it may cause a fibrous union, so refer him for a suitable denture.

If the patient is a CHILD manage his fracture as if he were an adult, but remember the following differences: (1) Growth disturbances of his condyles may follow, particularly in condylar fractures. (2) Don’t use interdental eyelet wiring unless he has a sufficient number of firm teeth, either deciduous or permanent. (3) Don’t use interosseous wires, because you may damage his unerupted teeth. (4) Mild malocclusion will correct itself as his mandible grows and his deciduous teeth erupt. A bandage, as in A, Fig. 62-17, may be all he needs.