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224     JULY   8, 1944.]                 DE TAL ASPECT OF MAXILLO-FACIAL SURGERY.                                           [    JOURNAL.

time not to drink too much. Well, I can tell you thi : that              The Dental Aspect of Maxillo-Facial
during my long life I ha'·e found that the more I have drunk
the better I have been"! And he went off into an almost                              Surgery.*
demoniacal chuckle. It only how how some constitutions can
stand anything! In those long-ago day, when the eye was
 the ouly legitimate speciality that was practised, the rest of                  By H.    GOLDIE,   D.D. ., .llajor,   .A.M.o.
us were "Jacks-of-all-trades". I was Hou. Visiting urgeon
to the Somerset Hospital and had a large general, midwifery
and surgical practice.
   I remember one exhausting occasion when I attended two
 midwifery deliveries through the night, and just got finished
                                                                       T    OWARDS the end of the last war it was considered
                                                                              essential in England that all patients with facial injuries
                                                                       should be concentrated at special centres for correct treatment.
 to do an abdominal operation at 8 in the morning!                     The bitter experiences of the earlier days of the last war led
   When I was Consulting M.O.H. I was in charge of the                 to the immediate establishment of maxillo facial teams all over
 Smallpox Hospital at Rentzkie's Farm, about 6 miles away             England at the outbreak of the present conflict. This was a
from my Church Square house. There were often limited out-             recognition that treatment of fractures of the face bones
breaks of mallpox at that time, and for quite long periods I           might have been neglected, perhap be.:ause the treatment lies
started my day by going out to the Smallpox Hospital at 6 a.m.,        in the field between general surgery and dental surgery. A
often on my bicycle, getting back to breakfast and then pro-           dental surgeon might never see a fractured mandible, and a
ceeding with my ordinary day's work! I was attending con-              general surgeon might be inclined to treat a fracutred mandible
finement at the same time, and on one occasion a lady I had            on surgical lines only. This work calls for the closest co-opera-
confined developed a high temperature and a rash indistinguish-        tion between the general and the dental surgeon. It was the
able from the very early smallpox rash. I spent a terrible             recognition of the importance of this that led to the estahlish-
couple of days and nights, but, thank Heaven, it turned out            ment of two maxillo-fa~ial centres in South Africa---ilne at
to be measles! Well, it was all very interesting, though strenu-      Brenthllrst and one at Rol::erts Heights. We have treated 150
ous. One attended colds, sore throat, pneumonias, all the              case, in the lasL 18 months, of mandible fractures alone.
infectious diseases, venereal diseases, confinements; did abdomi-         In hospital one sees many cases of non·union, mal-union,
nal sections, amputations, mastoids, tonsils, etc., etc. I had         osteomyelitis, and facial deformities in general, following frac-
as patients nervous ladies with very little wrong with them,           tures which have been inadequately treated or perhap evell
and fathers who took too much alcoh91! One acquired great              untreated, very oft~n through no f&u1t of the practitioner.
prestige after ordering a bicarbonate of soda mixture, and W36         Patient who receive a blow on the face may get a black eye
blamed freely if a complicated operation went wrong. During            and a swollen face and never suspect that the underlying bony
my last 12 years of practice I confined myself to a speciality,        structures have suHered damage. Yet some of the most com-
but I found it far less interesting than all my previous years.       plicated cases have resulted from a blow on the face with a
The old G.P. with a surgical bent saw life with all its many-         fist. A so-called simple fracture remains for a while unsus-
sided facets, and I look back to those first years of my pro-         pected until after a short period we find that we are dealing
fessional life as a time crowded with the memory of anxious            with a compound, complicated and very septic fracture.
moment and many happy, interesting day.
                                                                         The primary object of treatment in fracture of the jaw is
                                                                       restoration of function even in those cases with loss of con-
                                                                      siderable bone, and the criterion of success is the re toration
                                                                      of occlnsion to its earlier state. By proper occlusion we mean
   Die nuwe ho pitaal op Malmesbury is 'n n-oderne gebou met          when the teeth are closed in their correct position with the
twee operalliekamers.                                                 lower teeth fitting into the upper. It is particularly important
   Die ko te van die gebou i £41.000. terwyl die uitrusting           to avoid the collapse of bone egments. Many of the horrible
onO'eveer £10,000 sal beloop. Die ou hospitaal sal nog gebruik        deformities resulting because of the failure to maintain bone
word vir medie e behandeling, terwyl in die nuwe uitsluitend          segments can be avoided by the proper type of treatment. To
chirurgie e gevalle behanqel sal word. Verba send veel werk is        thi end main fragments of a fractured lower jaw should be
in die \"erlede in die ou gebou gedoen. Gedurende 1943 is b. v.       fixed in normal occlusion with the upper jaw.
800 pasiente behande!. van wie 744 geopereer is, en dit terwyl
slegs 32 bedden beskikbaar was. Die aantal pasiente wat in               There is no limit to the ingenuity displayed to ain this.
die toekom behandel sal word. sal du seker minstens ver·              The ca e is relati,·ely simple when the teeth are standing on
duhbel-'n feit wat be onder veel sal beteken vir die omlig-           both sides of the fracture, but such is seldom the case.
gende distrikte en die hele .:.\'"oordwestelike Kaapland, van waar       One of the commonest sites of fracture is through the lower
die mee te pasiente kom.                                              wisdom tooth or behind the last tooth. There i a posterior
                                                                      edentulous fragment which is very hard to control as there are
                      *              *      *                         no teeth to cement or wire a splint to. The actions of the
                                                                      muscles are to pull the short posterior fragment up, or it
   " Retina" is the succpssor of .11yollflo, the medical students'    might get displaced outwards or inwards and also rotated.
paper of the Univer ity of Cape Town. The first number is
intere tin . and contains an introductory appreciation by Pro-           The simple act of swallOWing mean a constant movement of
fessor Rvrie. Dean of the Medical Facultv. The Afrikaan               the fragment. The hyoid group of muscles at the same time
editorial - tate :                             .                      pull the anterior larger fragmlmt down and hackwards and
                                                                      inwards. This type of ca e ha always challenged the in enuity
   " Ons staan egter voor ·n ander moeilikheid. Die gevalle wat       of the worker in maxillo facial snrgery, but a great advance
met klinie e aande voorgedra word i uitsluitlik in Engels             has recently been made with the introduction of he external
op este!. en moet du a      ulks gepubliseer word. Hierdie ge-        or extra-oral splint.
valle be laan ten minste vyfti per ent van die blad.          besef      But. however useful and indi pensable in some cases of
dus dat on deuel lam ge.laan i sonder            medewerking.         fracture of the jaw, the extra oral or external splint does not
  " Die toekoms van Afrik'lan in hierdie blad hang uit luitlik         upersede any of the accepted and well-tried method. It is,
van u onderneming gee af. Daar i sover bekend nog nooi                however, most applicable to that fracture which ha hitherto
met 'n Kliniese aand 'n geval in Afrikaans voorgedra nie.             been least easily controlled-namely the fracture at, or near,
Hoekom nie?                                                           the an.,.le of the mandible where you have the ;.hort edentulous
   "Veral met die oog op die Afrikaan e Medie e kool te               fra m:nt. It is of great 11 e also in fracture of the edentulous
Pretoria i dit ab oluut nood aaklik dat ons aan 'n su ter-            mandible. These extra-oral methods are not devoid of the
Universiteit Afrikaan bewu in die :\lediese Fakulteit word.           risk of bone infection and ub equent necrosis, and should
Moenie moenie daar op          ewa word nie. Daar le baan-            be reserved for ca e in which more conservative methods of
brekerswerk \"oor!"
  The printer' error and lip hod tyle of the three clinical
contribution to the fir 1. number may be pardoned, but we               .. Joint presentation to    orthern Transvaal Branch of the
trnst that future issues will be more rigorou ly ubedited.            ~ledical  Association.
                                     DENTAL ASPECT OF MAXILLO-FACIAL SURGERY.                                      [J ULIE 8 1944.   225

treatmeut are not likely to be So far it has been           We hope to get our straightforward fradured jaws out of
deemed necessary to immobilise the Jaws with intermaxillary           hospital after 6 weeks, but unfortunately we also have manl
fixation as well for a short period.                                  cases which do not have this happy re ult mostly because of
                                                                      the complications of sepsis.
   In some areas it is not important that the fragments be
 restored to the original position. This is partic~larly .true ~f       After much experience in the treatment of fractured jaws
the neck of the condyle and coronary process. Sunple unmobl·          we come to the conclusion that there is 110 certainty that a
lisation of the Jaws does very well. Mnch ha~m can be done             imple fracture is going to remain a simple fracture. One may
 by attempting radical procedures. Open reductIon of fractures        have been lucky with a simple treatment uch as a bandage,
of the mandible is less often indicated than many general sur-        but the frequent unnecessary complicatiom, deformities, and
 geons seem to realise. So often simple immobilisation of the         lack of function 0 often seen following facial injuries would
lower jaw to the upper for three we~ks ~IV~S ~ good fibrc;lUs         suggest that the treatment has perhaps not always been entirely
 union and normal function. If the Jaw IS mclIned to swmg             adequate.
over, a training flange will soon correct this tendency. ~ven
if the position looks all wrong in the X-ray, .a &ood fu~ctlOnal
re ult is the rule. If an open operatlOn IS Illdlcated, It must
 be because of interference with function. A bilateral condyle         The Surgical Aspect of Maxillo-Facial
fracture should be immobilised for 8 weeks as there is a ten-                       Surgery.
dency for the elevator muscles to cause an open bite.
  Fracture of the mandible occurs 30 times as often as fracture
of the maxilla, from its vulnerability and mobility. . Frac-              By   c.   A. R. SCHULENBURG, F.R.C.S., J/ajor, S.d.M.C.
tures of the mandible are perhaps most commonly m the
following order:
         The premolar and canine area.
                                                                      T HE surgical aspects ofpnreears, but the work with whichthe.:.
                                                                            deal do not include
                                                                      face, eyelids, mouth, nose and
                                                                                                      soft tissue plastic work on
                                                                                                                   following: 1. Some
         The angle.                                                   points in first aid; 2. Fractured mandible-recent fractures,
         The symphsis.                                                later stages; 3. Fractured maxilla; 4. Fractured zygoma; 5.
         The neck of the condyle.                                     Fractured nose; 6. l\Iidface crush; 7. Frontal sinus crush.
         Coronoid process.                                                Pirst did: There is really only one point to be emphasi ed
                                                                      in first aid-in any severe injury about the face, with cru hing
          igmoid notch.                                               or comminution of jaws or facial bones, and where bleeding
                                                                      is present or likely, a free airway must be provided. It is
    Each ca e presents a dilierent problem, and the success           easy to see how the tongue will fall back' if unsupported by
attained is in direct ratio to the ingenuity exercised. Frequently    a comminuted mandible, how blood will choke the unconscious
 the succe seg quoted omit the difficulties which all practitioners   patient and how death may be rapid. If the patient is placed
encounter at some time. The more fractures one treats, the            on his face 01' side, the tongue pulled forward by any means
more convinced one becomes that the type of splint to be u ed         whatever, the throat cleared, and hremorrhage controlled, a
is u ually governed by ~he kind of fract!-,re and type .o~ patient.    life is saved. If the case i desperate, the expedient of
   Imple cases are sometimes treated by Il:,terdental wIring: The     tracheotomy or laryngotomy must not be forgotten. This will
treatmeut which has proved most ucce-sful III our hand IS that        save life and will provide an ideal airway for administration
which we have adopted a our routine, i.e. sectional metal cap         of an anre thetic when the surgeon wi he to attend to the
splint. The edentulous jaw is treated either by d:cumferential         face, unhampered by the ame theti t and his tubes.
wiring or by extra-oral splInt. Condyle fra~ture Ill. edentu.lous
ca es, i.e. cases without teeth, are treated With Gunnlllg splint,       The common- ense first-aid measures for more imple frac-
and- the mouth is kep.t at re t by pIa ter head .cap. and ela tic     tures con i t of the various form· of bandage and interdental
traction round the chill. We remove all teeth m hne of frac-          wiring.
ture except in very exceptional circum tances and when we                 .\J andible: (a) Recent fractures requiring surgical servi es :
remove lower wi dom teeth we attempt to control the posterior         :\lajor Goldin has outlined the routine treatment of the com-
fragment with an extension.                                           nlOner fractures of the mandible, tre ing extraction of teeth in
    Many wondel· how the e patients eat their jaw.s so          line of fracture, and plintage in correct ccdusion, etc_ There
 tightly immobilised.      They a su t~llllng a?d highly         are certain cases where surgical interference i nece ary in a
                                                                       recent fracture.
 nutritious diet. The weekly weIght chart IS our gmde. Very
 few non-Enropeans suffer from malnutrition in the Army-yet               (i) 'I'he .. posterior edentulous fragment" 1eith gro.'s dis-
many such patients show an increase in weight in the ward.            placement: The fracture is behind the wisdom tooth or in line
    The angle fractures unite sooner than t!le symphyseal frac-       of the wi dom, which is extracted.      ·ow the posterior fragment
 tures. We u ually get complete clinical union at the angle           may be displaced upwards by the pull of the internal pterygoid
                                                                      and masseter plus temporal muscle. and inwards by the pull
between 5 to 6 weeks.
                                                                      of the internal pterygoid. Reduction and retention of thi·
    The sectional cap plint allow u to test for nnion very             fragment may be done intra-orally. In ome ca es this is
easily and the usual tes~ for clinical union al;;o apply to the        un atisfactory and we use two methods for thi fracture:
 mandible. We do a fall' amount of fre henlllg of bone at                 1. 'urgicat wiring-the fracture i exposed through external
 fracture ites in cases of delayed union, and find them highly         incision, reduced under vi ion, and a loop of vitallium wire
  ucce sful-although this usually means a slight sacrifice of          in erted through small drill holes.      ~ aturally the jaws are
occlusion to avoid a bone graft_                                        plinted to ether_ by ca t metal cap plint in the usual way.
    Fracture of the maxilla do not need a long a treatment a              2. Extra-oral splint. We use the Brenthurst clamp splint,
 do fracture of the mandible. After primary connective tissue         devised by ~1ajor Penn and Major Brown. The inferior border
or a callus has formed, the parts are usually self-retained           of the mandible i exposed through a small inci ion on either
 becau e there are no trong muscle attachments which tend to            ide of the fracture, the clamps are applied the fracture i
 displace the fragments.. A .complication o! the ~ractnres of          manipulated into position, and the clamps are united by cro
the maxilla may be an mfectlOn of the maxillary slllnses_             bar and a serie of universal joint. The clamp splint is a
      nfortunately fracture of the jaw do not pre ent only a          good answer to thi fracture-we usually plint the teeth
 mechanical problem_ It mu t be remembered that mo t of               together in any case for the first few week", but thereafter the
 these fractures are compounded into the mouth, and the que -          patient i aHowed to move hi jaw and enjoy a full diet.
tion of infection is aJway· pre ent.    ome urgeons go so far a          (ii) Bilateral fracture of the edentulous mandibte, with gross
to make a practic,: of sub-mandibular drainage at the ti!"e of         displacement: Reduction and retention may be difficult or
 immobilising the Jaw. We feel trongly that sub-perlo teal            impo ible by ordinary means, e pecially if it i a bilateral
  wellings should be incised more frequently and sooner than          angle fracture. with forward rotation of the middle fragment
 has been the habit in the pa t.                                      -extra-oral splints on both ide are used.

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