mandibular fracture

British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

Mandibular fractures: Historical perspectiveR. Mukerji a, G. Mukerji b, M. McGurk a,∗a Department of Oral and Maxillofacial Surgery, Guy’s and St. Thomas Hospital, Salivary Gland Service, Floor 23, Guy’s Tower, London SE1 9RT, UKb Hammersmith Hospital and Imperial College, London, UK

Accepted 24 June 2005Available online 19 August 2005

Abstract

The principles of the treatment of mandibular fractures have changed recently, although the objective of re-establishing the occlusion andmasticatory function remains the same. Splinting of teeth is an old way of immobilising fractures but the advent of modern biomaterials haschanged clinical practice towards plating the bone and early restoration of function. We present a brief historical overview of techniques andsystems that have been used for stabilisation of mandibular fractures.© 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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eywords: Mandibular fractures; Historical review

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t is important to view historical reports in the context ofheir time. Historical insight improves understanding of cur-ent techniques and provides the basis for the development ofew methods. From the time of Hippocrates, physicians haveescribed many different techniques for treating mandibularractures, the principle of which has always been reposi-ioning and immobilisation of the bony fragments. How-ver, during the past 50 years, perfection of anaesthetic andadiographic methods, introduction of antibiotics, speciallyesigned instruments, and advances in biomaterials havellowed maxillofacial surgeons to improve outcomes whileeducing morbidity. In this paper, we review the evolutionf the management of mandibular fractures from the Persianeriod to the present day.

he pre-Christian era

he first description of mandibular fractures dates to the 17th

Luxor in 1862 and later translated by Breasted.1 The Egyp-tians’ attitude to mandibular fractures was rather pessimistic:

“If thou examinest a man having a fracture in his mandible,thou shouldst place thy hand upon it . . . and find that fracturecrepitating under thy fingers, thou shouldst say concerninghim: One having a fracture in his mandible, over which awound has been inflicted, thou will a fever gain from it. Anailment not to be treated. Death usually followed, presumablycaused by infection”.

However, the documents show that simple fractures of thejaw were treated by bandages, obtained from the embalmer,and soaked in honey and white of egg, while woundswere treated by the application of fresh meat on the firstday, a method which may well have introduced tissueenzymes and thromboplastins without, one hopes, too manybacteria.

Historically, medicine (healing) and religion have alwaysbeen entwined. In the Hellenic period, temples to Asklepios

entury bc in the ‘Edwin Smith papyrus’, bought by Smith in

∗ Corresponding author. Tel.: +44 207 188 4348; fax: +44 207 188 4360.E-mail address: [email protected] (M. McGurk).

were set up and the secular assistants to the priests, knownas Asklepiadae, helped provide medical treatment. To oneof these assistants in the year 460 bc on the island of Cos,was born a son, Hippocrates. He looked at medical problems

axillofac
266-4356/$ – see front matter © 2005 The British Association of Oral and Mdoi:10.1016/j.bjoms.2005.06.023
ial Surgeons. Published by Elsevier Ltd. All rights reserved.

R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228 223

from a more practical and mechanistic perspective, relyingless on religious explanations. Hippocrates not only devisedthe technique of reducing a dislocated mandible, which stillcarries his name, but also taught methods of immobilising afractured mandible. The ends of the fracture were reducedby hand and the fracture site was immobilised by gold orlinen threads tied around the adjacent teeth. In addition tothis intraoral immobilisation, he recommended extraoral fix-ation by strips of Carthaginian leather glued to the skin, theends of which were tied over the skull (Interestingly, thebarrel bandage was still in use two centuries later.). Accord-ing to Hippocrates, the fracture healed within 20 days whenusing this method of fixation, provided that no infectiondeveloped.2

The early medieval period

During the period of the Roman Empire (23 bc–410 ad) fewif any true advances were made in the treatment of mandibu-lar injuries, and reliance was placed upon the traditionalHippocratic methods. The Romans emulated Greek medicalthought; the Roman encyclopedist Aulus Cornelius Celsuscollected Greek and Roman medical thought in a series ofvolumes entitled Artes. Celsus addressed the treatment offractures of the jaw in the eighth volume.1 In general, heacttGttss

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using complicated bandaging and bamboo splints coveredwith a mixture of flour and glue that were applied under thechin to immobilise the fractures.3

The 17th and 18th centuries

The association between medicine and religion extended intothe Christian era, but when the Pope in 1163 ruled that anyoperation involving the shedding of blood was incompatiblewith the priestly office, the “barbers” took over the prac-tice of rudimentary surgery. So from the Middle Ages tothe early 1700s, much dental treatment was provided byso-called “barber surgeons”. These jacks-of-all-trades wouldnot only extract teeth, treat facial fractures, and undertakeminor surgery, but they also cut hair, applied leeches, andembalmed corpses.4 During this period (12th to early 18thcentury), the barber surgeons used the classical treatment offractures. After manually resetting the fractured jaw, ensur-ing that the normal occlusion was maintained and the teethadjacent to the fracture line were joined by ligatures, themandible was immobilised by bandages. Various modifica-tions of bandages were used to immobilise the lower jawby binding it to the upper jaw by a bandage that passedunder the chin and over the head.5 It was prevented fromslipping by another bandage carried over and around theo

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dhered to the treatment advocated by the Corpus Hippo-raticum: “The fragments are repositioned using two fingers,hen tie together with horsehair the two adjacent teeth, or ifhese are loose, tie them to teeth further away.” Taking thereek example further, Celsus advocated a ligature for fixa-

ion of the fracture. Postoperative treatment included rubbinghe injury with wine, oil, or flour. He forbade his patients topeak and told them to live exclusively on liquid food foreveral days.

About 500 ad, the Indian surgeon Sushruta wrote a treatisen operations. He recommended treating fractured jaws by

Fig. 1. Bandages to immobilise the lower jaw: Garrets

cciput (Fig. 1).The 18th century saw a more scientific approach to

edicine as a result of advances in the knowledge of anatom-cal and physiological processes. The era of scientific den-istry was ushered in by the publication of a book in 1728y Pierre Fauchard, entitled Traite de chirurgie dentaire.6

e was the first to describe a comprehensive system forhe practice of dentistry including basic oral anatomy andunction, operative and restorative techniques, and construc-ion of dentures. He is credited with being the “Father of

odern dentistry”. Although Fauchard did not make any

ft) and Hamilton’s (right) (reprinted from Stimson5).

224 R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

special contribution to the treatment of fractures of thejaw, the impetus that he gave to the development of den-tal prostheses stimulated others to devise techniques for thecontrol of the fragments of the dentate jaw other than bythe use of simple ligation of the teeth and support from abandage.

As might be expected, the simple ligatures used to bindaround the teeth were unable to hold the fragments of jaw ina rigid position, so the fracture was unstable. Bunon soughtimproved stability when, in 1743, he used a carved ivoryblock as a dental splint to which he tied all lower teeth bythreads.7

In 1779, Chopart and Desault described a simple dentalsplint, essentially a shallow trough of iron laid over the lowerocclusal table which was clamped down to the lower borderof the mandible by an external screw device (Fig. 2).8 Varia-tions of this principle were employed for a long time, beingintroduced into Germany by Rutenick in 1799, who appliedfurther stabilisation by a head harness attached to a helmetby ribbons.9

Fa

The 19th and 20th centuries

At the turn of the 19th century, there was a gradual shift inthe management of fractures of the jaw away from generalsurgeons to dental surgeons, because the management of frac-tures depended on manipulating the dentition. Modern dentalmaterials facilitated the construction of dental splints. Thesewere the domains of the dental surgeon. The work has subse-quently remained the remit of the dentally based specialties.

Many refinements were introduced by improving intraoraland extraoral splints or the use of either trans-mandibular orcircum-mandibular wire fixation to immobilise the mandibu-lar fracture directly or indirectly.

External fixation often caused infection and the risk ofmalocclusion. In 1826, Rodgers did one of the first openreductions. He inserted wire sutures in a case of pseudarthro-sis of the humerus.2 Baudens is credited with being thepioneer of wiring mandibular fractures, and as early as 18402

he used circumferential wires to immobilise an oblique frac-ture. Soon after (1847), Buck applied wire sutures directly tothe fractured bone by drilling holes in adjacent segments andwiring them together.10 Modifications of this technique byusing two double wires (Rose) and the figure-of-eight wiresuture (Raas) improved stability,2 but before the advent ofantibiotics few intraoral wounds healed without infection.

Up to this time, all fractures of the jaw were reduced manu-aTroit

ig. 2. Apparatus to immobilise a fracture mandible according to Chopartnd Desault (1779) (reprinted from Rowe10). F

lly, without the aid of anaesthesia as an outpatient procedure.he introduction of anaesthesia by Dr. Horace Wells in 1844

evolutionised the practice of surgery.11 Speed was no longerf paramount importance and a degree of finesse could bentroduced with improved results. This also applied to frac-ures of the jaw.

ig. 3. Kingsley’s splint (top) and applied (bottom), 1855 (from Stimson5).


Fig. 4. The Gunning splint (1866) (reprinted from Siegert2).

In 1855, Hamilton introduced the gutta-percha splint thatwas prepared in the patient’s mouth after reduction of thefracture. This splint enjoyed wide application, particularlyduring the American Civil War.10 Kingsley devised a splint,“Kingsley’s apparatus” (Fig. 3), with attached bars by whichthe splint and the jaw could be bound firmly together with anoutside bandage passing from one bar to the other underneaththe chin.5 In 1858, Hayward developed a metal splint forseverely dislocated fractures, the splint being adjusted to theindividual needs on the basis of a plaster model of the jaws.12

This was a new development. A cast was made of the lowerjaw, it was sectioned through the fracture site and the dentalocclusion realigned. A splint was made to the new occlusionand covered the surface of the teeth. The fragments of thejaw were forced into the splint, so effectively reducing thefracture.

In 1866, Thomas Gunning designed the ‘Gunning splint’for Mr. William Seward, the Secretary of State to AbrahamLincoln.13 Seward had bilateral fractures of the body afterfalling out of a carriage. The splint was a single piece ofvulcanite with a space for eating (Fig. 4). Screws were usedto attach the splint to the hard palate and the mandible. Amodified form of the Gunning splint is still used today.

In 1871, London dentist Gurnell Hammond developed awire ligature splint for immobilisation of the mandible.14 Animpression was taken of the teeth and cast in stone. The dis-placed segments were realigned on the stone model and thena heavy iron wire was adapted to the teeth on the model. Thebar was subsequently wired to the patient’s natural teeth, sopulling the misaligned fragments into line. The basic tech-nique is still used today in the form of arch bars.

In 1887, Thomas L. Gilmer reintroduced intermaxillaryfixation (a technique that had been forgotten for centuries)and the use of arch bars for mandibular fractures.10 His tech-nique is still superior to other methods of fixation in certaincircumstances such as communited fractures and fracturesof an atrophic mandible. However, the drawback of his tech-nique is that it can be uncomfortable, and pain—together withthe change in diet from solid to liquid—can lead to loss ofweight and poor nutrition.

Dr. Angle (1890) introduced an alternative to wiring thesegments of the jaw. It consisted of banding teeth on eitherswAooat

sff

’s interm
Fig. 5. Angle’s apparatus (a) and Angle
ide of the fracture, and then bound in the bands together byire to immobilise the fracture—Angle’s apparatus (Fig. 5a).ngle’s method of fixation of a broken lower jaw to an intactne (intermaxillary fixation) was effected by placing bandsn the teeth of the upper and lower jaw and around the shortrms fixed upon these bands wrapping a wire that holds themogether, so using the upper jaw as a splint (Fig. 5b).10

Hippocrates said: ‘War is the only proper school for aurgeon’ and much impetus to the improved management ofacial fractures came with the mobilisation of whole nationsor the First and Second World Wars. Trench warfare resulted

axillary fixation (b) (from Stimson5).


Fig. 6. Amex casque, designed by American Expeditionary Forces (WorldWar I) (reprinted from Strother,20 copyright (2003), with permission fromthe American Association of Oral and Maxillofacial Surgeons).

in extensive maxillofacial injuries in thousands of soldiers.Military surgeons were forced to improvise in devising appli-ances for their patients and often created splints from coins,telephone wire, or meat tins. The Amex casque (Fig. 6)designed for the American Expeditionary Forces, becamepopular with French and British military surgeons.15 It hadan adjustable steel band, fitting around the circumferenceof the head, with adjustable cranial bands and an adjustableperpendicular rod and horizontal face bow. This applianceaccomplished fixation of either soft tissue or bone fragmentsand was used for many patients with injuries of the head andjaw.

Dr. Varaztad H. Kazanjian, the chief dental officer at Har-vard University was sent to England to assist the Britishin caring for injured soldiers in the First World War.3 Heestablished a treatment plan for previously unmanageablemaxillofacial injuries by wiring together small fragmentsof shattered jaw bone, and construction of special splintsand internal vulcanised rubber supports that prevented theface from contracting until surgeons were in a position tograft bone and skin on to the damaged areas. Because of theextraordinary success of his techniques, British journalistsdubbed Kazanjian “the miracle man of the Western front”.Kazanjian not only created a unique treatment for maxillo-facial fractures, he also was a pioneer in the field of modernreconstructive surgery.

ono

Fig. 7. ‘Fixateur externe’ developed by Grace George Ginestet in 1936(reprinted from Hausamen,14 copyright (2001), with permission from theEuropean Association for Craniomaxillofacial Surgeons).

wire ligature, which later became popular and was known asthe ‘Ivy loop’.

Although the first percutaneous nailing of fractured longbones was by Parkhill as early as 1897,16 the use of Kirschnerwires to treat mandibular fractures was published only in1932.2 After restoration of normal occlusion, the fracturedfragments were fixed with a pin inserted transcutaneously.The ‘fixateur externe’ developed by the Ginestet, 1936(Fig. 7), became popular in the management of complex facialinjuries encountered in the 1939–1945 war and was in com-mon use during the period of the Vietnam War.14

Development of osteosynthesis

Modern traumatology started with the development ofosteosynthesis, which was a major step forward in cran-iomaxillofacial surgery. Before its advent, most mandibularfractures were treated either by approximate fixation usinginternal stainless steel wires, external fixation using rigidmetal pins, or custom-made silver cap splints (cast metal cov-ering of all the teeth in the arch).

The first osteosynthesis plate was used by the Britishsurgeon Sir William Lane over 100 years ago.17 The ideawas in advance of its times, because the technology forptscmL

During the next few decades, there were many variationsf splinting and techniques of intermaxillary fixation, mostotable by Robert H. Ivy (1922).10 He modified the techniquef intermaxillary fixation by creating a loop (eyelet) in the

lates to be biocompatible and the problem of sepsis had firsto be overcome. It was not until 1943 that Bigelow describedcrews and bars made of vitallium—an alloy of cobalt,hrome, and molybdenum—for use in the management ofandibular fractures.18 It was only in the late 1960s (whenuhr19 (Fig. 8a) and Perren et al.20 developed plates with


Fig. 8. Osteosynthesis plate introduced by Hans Luhr19 (a). Miniplates developed by Champy and Lodde21 (b) (reprinted from Hausamen,14 copyright (2001),with permission from the European Association for Cranio-Maxillofacial Surgeons).

cone-shaped or spherical screw heads and compression holesthat were congruent in shape and initiated their large-scaleproduction) that the way was paved for osteosynthesis to begenerally accepted in the treatment of facial fractures.

Pauwels reported that the most favourable site of internalfixation of a fractured bone was where the muscular tensileforces were at their greatest. Champy and Lodde in the early1970s applied this ‘tension band principle’ (also referred to asChampy’s principle) to the mandible in mathematical, biome-chanical, and clinical studies.21

The first plates were still bulky, and were designed exclu-sively for use in mandibular fractures. Miniplate osteosyn-thesis was first introduced by Michelet et al. in 1973,22 andfurther developed by Champy and Lodde in 1975 (Fig. 8b).21

Spiessl introduced the lag-screw technique of osteosynthesisin1974.23 These screws had threads on the distal end and asmooth shank at the proximal end which allowed compres-sion of the segments between the outer and inner components.

During the following two decades a large number ofmodifications of plates were described,24–26 which led tothe present use of osteosynthesis. In the recent times, Ellishas done extensive work on non-compression, monocorti-cal plates for mandibular fractures, particularly those of thecondyle and angle.27 Today, many different systems are avail-able, ranging from the heavy compression plates for mandibu-lar reconstruction to low profile plates for midfacial fixation.Tmbhm

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Icfw

Odontological Society in October 1899 that he had treatednumerous fractures and never seen a case where there wasany internal or external wound except at the fracture site.29

He reported that dental surgeons were never called upon tostitch a wound or to arrest undue haemorrhage. This contrastswith the injuries sustained in high-speed road traffic crashesof today. Nevertheless, many facial fractures are still causedby interpersonal violence and can be considered simple.30

External appliances fixed to a head cap and semi-rigidimmobilisation by wire suspensions that are cumbersome tothe patient and entail long period of immobilisation have beensuperseded. These simple but crude techniques should notbe deprecated because they are effective and can be reliedon when modern facilities are not available. The improvedresults are derived from a better scientific approach to thebiomechanics underlying the function of the jaw, and the tai-loring of new techniques and biomaterials to these principles.It has also been made possible by the general advances, withcontrol of infection and improved surgical instruments.

Conclusion

The treatment of fractures of the jaw has a long history, fromancient Egypt to the present. Today’s oral and maxillofacialssjwpawdtgwmap

he thickness of plates ranges from 0.5 to 3.0 mm and areade either of stainless steel, titanium, or vitallium. Recently,

iodegradable, self-reinforced polylactide plates and screwsave been used for the internal fixation of fractures of theandible with good results.28

eflection

n reflecting on the evolution in technique through the 19thentury to today, one needs to appreciate that the type ofracture was different then from now. In 1895, the fracturesere relatively simple. Dr. F. Weisse reported to the New York

urgeons are recipients of knowledge acquired from manyurgeons through the ages, including Hippocrates, Kazan-ian, and Lane. In the 18th and 19th centuries, fracturesere treated quite successfully in outpatients. During thateriod the potential for sepsis was ever-present and access tonaesthesia limited, so treatment was conservative; the teethere simply repositioned (without anaesthetic) using ban-ages and dental splints to hold them in alignment. Today,his work is undertaken in a more sophisticated way undereneral anaesthesia. The ability to control infection togetherith the advent of new biomaterials has revolutionised treat-ent. Now open reduction is the norm and tiny titanium plates

re used to immobilise fragments of the jaw. Morbidity of therocedure is low with the advantage that the patient returns


to normal function within days of treatment. But low mor-bidity comes at a price of expensive materials and the needfor inpatient hospital facilities.

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mandibular fracture

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