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S.A.MEDICAL 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. S.A. TYDSKRU' VIR] DENTAL ASPECT OF MAXILLO-FACIAL SURGERY. [J ULIE 8 1944. 225 GENEESKUNDE. treatmeut are not likely to be eliecti.ve. 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 maxillo-facial 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 w.it~ their jaw.s so line of fracture, and plintage in correct ccdusion, etc_ There tightly immobilised. They g.et 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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