Scope and General Principles

The treatment of major injuries of the lower half of the face is essentially a matter of teamwork between plastic surgeon and dental surgeon. The way in which the dental surgeon is likely to be involved may, for the sake of conciseness, be stated under the following headings:

Early Treatment:

(a)	Assisting with intra-oral surgery involving the removal page 374 or conservation of comminuted bone fragments, displaced teeth and lacerated soft tissue.
(b)	Reduction and fixation of fractures of the mandible and maxilla.

Delayed Treatment:

(a)	Generally assisting with bone grafts to the mandible, and with intra-oral skin grafts.
(b)	The provision of temporary or permanent prostheses.

Note: The term ‘early treatment’ refers to early specialised treatment, and not to what may be described as first aid or preliminary field treatment.

It is advisable to outline the principles of treatment in order to provide a background, against which methods of treatment and general policy may be recorded as they evolved during the Second World War.

As far as the healing of wounds in general is concerned, the jaws and face have one great advantage, and that is their copious blood supply; consequently, in major injuries of the jaws it is possible to be much more conservative with comminuted bone fragments and lacerated soft tissue than it is in other regions of the body. (Figure 2.) On the other hand, the jaws have one great disadvantage in this respect, and that is the presence of teeth; teeth adjacent to the site of fracture may be the cause of complications if they are fractured themselves, displaced, have their adjacent mucoperiosteum detached, or even if they are intact. It is remarkable to see how much more readily healing and union occur in a grossly comminuted fracture of an edentulous mandible than in a similar fracture where teeth are present.

When, however, it comes to a question of reduction and fixation of jaw fractures, the presence of teeth is usually an advantage. In minor injuries sufficient fixation for a fractured mandible was often obtained by wiring the mandibular teeth to those of the maxilla (‘inter-dental’ wiring). But in major injuries it was necessary to construct ‘cap’ splints, of cast silver, which fitted accurately over the mandibular teeth and were cemented on to them so as to bridge the region of the fracture. (Figure 3.)

In many cases, however, owing to lack of teeth or the fact that the fracture was in a posterior region of the mandible, neither inter-dental wiring nor cap splints was effective. In such cases the most satisfactory method of fixation was by intra-osseous pin fixation; the pins were inserted extra-orally through the skin surface and drilled into the bone fragments where they were left anchored with their ends projecting through the skin; a pair of pins was placed in each fragment, and after reduction the two pairs were rigidly joined by a special clamping appliance. (Figures 1 and 5.)

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This casualty occurred in 1941, before the advent of penicillin

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A cast metal cap splint on the mandibular fragments with a bar bypassing a central incisor tooth in the line of fracture. There is a cast metal splint on the upper jaw and both splints show hooks for intermaxillary rubber fixation. Owing to the ‘floating’ condition of the maxilla an extra-oral bar is fixed to a plaster skull cap by means of bars and universal joints

Owing to the obliteration of the upper buccal sulcus and soft-tissue damage it was necessary to line the upper buccal sulcus with an epithelial inlay. This photograph shows the splint and removable tray on the plaster model used in its construction

Showing the epithelial inlay graft and the now adequately deep upper buccal sulcus

The skull cap and extra-oral fixation apparatus used. The extra-oral bar is bent up in relation to the nose tip so that the patient can use a cup or glass for drinking and the extensive soft-tissue laceration with the lower lip healing in a grossly displaced position

The same splint in position on the patient

The patient wearing his partial upper and lower dentures illustrating the

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This graft took completely giving an excellent functional result. Foot drop corrected by means of toe-raising spring

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Large skin and soft-tissue defect with exposed bone and septic cavity in the centre. Tendons of quadriceps visible. Redundant skin fold bottom right. In Thomas splint

Fenestrated pressure dressing. Window and cavity packed with ribbon gauze

Three weeks after operation. Complete ‘take’. Almost completelyhealed except for cavity. Note how redundant fold has been pulled into place and general improvement in contour of the limb