128 1. Smith

of the blow, when the posterior teeth are missing and also when the mandible is not fractured. Clinical ly the bleeding is ra ther l imited because there are no major vessels in this area. A high incidence of external audi tory meatus lacerat ion associated nei ther with basal skull fracture nor with condylar fracture was demon-

References Killey, H. C.: Fractures of the Mandible (2nd ed.).

Wright & Sons Ltd, Bristol 1971 Kristiansen, K.: Open or Compound Wounds of the

Head. In: G. F. Rowbotham: Acute Injuries of the Head (4th ed.). Livingstone Ltd. Edinburgh 1964

Rowe, N. L., H. C. Killey: Fractures of the Facial Skeleton (2nd ed.). Livingstone Ltd. Edinburgh 1968

strated in this series. I t should be mentioned that the reported incidence, derived from patients re- port ing to a casualty department , is more objec- tive than the incidence of the symptom in neuro- surgical or maxi l lo - fac ia l clinics where the inci- dence of basal skull fractures or condylar head fractures is increased accordingly.

Prof. Christos Martis, D.D.S., M.D., Ass. Prof. Demetrius Karakasis, D.D.S., M.D., Department of Maxillo-Facial Surgery, School of Dentistry, University of Thesaloniki, Thesalouiki, Greece

J, max,-fac. Surg. 2 (1974) 128-134 @ Georg Thieme Verlag, Stuttgart

Fractures of the Middle Third of the Facial Skeleton - A New Method of Treatment

Ian Smith

Head of the Department of Maxillo-Facial and Oral Surgery Johannesburg General Hospital and University of the Witwatersrand, South-Africa

Summary A new method of immobilization for fractures of the middle third of the facial skeleton has been devised. The intention of the described facial framc is to pro- vide an immobilization for these fractures which is totally independent of the mandibular segment, eli- minates maxillo-faclal technical laboratory assistance, and permits early or immediate freedom of movement of the intact mandible. The procedure is described in detail and pertinent observations have been noted. An analysis of the first 17 cases which have been treated by this method is included. The procedure has also been used as a means of immobilizing the maxillary segment when a Le Fort I maxillary osteotomy is untertaken to correct a facial deformity.

Key-Words: Fractures of middle third of face; Facial frame.

Introduction Various methods of t reatment have been ad- vocated to restore the f ractured facial skeleton

and most of them yield successful results. Whereas the simpler types of fractures are easily managed, the more complicated variet ies provoke a greater challenge in their treatment. Some of the methods of t reatment that promote a more r igid immobi- l ization of f ragments are; the Mount-Vernon "box frame" type of fixation, "Halo" frames (Mackenzi 1971) and cast metal cap splints with anterior connecting rods, and the Levant (1973) cranio maxi l l a ry f ixat ion technique. This new method is presented as a further contribution to the manage- ment of these facial injuries. W i t h this method, a facial frame which acts as a scaffold is suspended in front of the in jured face. From this r ig id apparatus an accurate reduction and f irm immobil izat ion of the numerous bony fragments is achieved without depending on the mandibular component. W h e n deal ing with fractures of the facial skeleton it is essential to make a thorough assessment of

Fractures of the Middle Third of the Facial Skeleton 129

the nature of the injury. Le Fort's classification of the middle third facial fractures is generally con- sidered to be the most suitable, but greater emphasis must be placed on the effect of the injury. It is necessary to determine whether the fractured segments are impacted or mobile, and to assess the degree and direction of the displace- ment. When a complex fracture is sustained some of the fragments may be freely mobile and badly displaced, whereas others are more or less stable and undisplaced. The most severe injury presents with all fragments being mobile and grossly dis- placed. These variable features must be ascer- tained, but exceptional difficulty may be ex- perienced with the diagnosis of the impacted fracture. This is particularly so with an impacted Le Fort I type of fracture. Obviously an assessment of the ocelusal relationship is an important facet in the examination of these cases.

Prior to treatment the method of reduction and the form of immobilization must be considered. Simple fractures are often merely reduced and remain stable, while the more complicated frac- tures require reduction and some form of immo- bilization.

It is noteworthy that the reduction of a selected fragment may effect a concurrent reduction of adjacent fragments. Often the reduction of the maxillary segment effects the reduction of an associated fracture of the nasal and zygomatic component. In cases where this is not achieved, all the components will have to be dealt with indi- vidually.

Similarly, through an adequate immobilization of one fragment, adjacent fragments may be satis- factorily supported.

In essence these numerous factors will influence the method of treatment and determine whether the reconstruction should be effected from above or from below.

Material and Technique

The aim of this new method of treatment is to provide a more rigid form of immobilization whereby the numerous facial segments will be securely held in their corrected position.

The facial frame used in this technique is made up of two sections. Each section is fashioned to a spe-

Fig. 1 A view of the assembled face frame. The segments of the frame have been tailored to a de- finite size and shape to accommodate any sized face.

cific pattern from l/s" (3.0 ram) stainless steel rods (Fig. 1). The upper section of the frame acts as the stable element and is fixed with universal clamps to two titanium pins which have been inserted into the frontal bone immediately above the supraorbital ridges. Moule's Vs" (8.0 ram) titanium pins, with a coarse thread of the type used for insertion into wood, are most suitable.

The lower section of the frame is fixed with Tower Clamps (Tower Manufacturing Co. Inc. Seattle, Washington, U.S.A.) to two Kirschner wires which have been inserted into the bone of the maxilla at two selected points directly under the floor of the nose. Following the reduction of the numerous facial fractures, the lower section of the frame is locked to the stable upper' section by means of universal clamps. For this technique .062" (1.6 ram) gauge Vitallium Kirschner wire is preferred and has been purposely selected because of its slight flexibility and the whip action that can be produced.

The apparatus is always set up in this fashion having a basic four point bony fixation. Addi- tional Kirschner wires are inserted into other individual fragments for their specific immobi- lization when this is required. These additional Kirschner wires are locked by means of Tower Clamps to the assembled facial frame. Alternately direct bony wiring of individual fragments is used in conjunction with the method.

Prior to the reduction of the fractures of the middle third of the face it is necessary to re-

130 1. Smith

establish the occlusion of the teeth, if teeth are present, eyelet wiring with intermaxillary fixa- tion is generally used. Occasionally cap splints may be required to restore the occlusal relation- ship of the teeth. In the edentulous jaw Gunn- ing Splints, or the patient's own dentures, are inserted to guide the reduction and establish the correct relationship of the upper and lower jaws. The impacted fracture of the maxilla will require special attention. Whereas cap splinting and elas- tic traction assists in the reduction of the impacted fracture. With this new method of treatment there is no leeway and the impacted maxilla must be completely reduced before the facial frame is locked. If difficulty is expeiqenced in maintaining the occlusion then cap splinting with elastic trac- tion should be used in conjunction with this method.

Insertion of the Supraorbital pins

A small incision is made in the eyebrow, gener- ally in the outer third, and the supraorbital ridge is exposed. Using a dental handpiece with a num- ber 6 flat-fissure burr, a drill hole is made into the bone. The hole must be correctly sited and angled at 45 ° to the coronal and sagittal planes and should not be placed further than half an inch (1.25 cm) from the orbital margin. Using a hand drill, the titanium pin is carefully turned into the hole. Through the eyebrow incision which may have to be extended, nearby fracture lines can be visualized and dealt with by direct bone wiring when necessary. The incision is sutured and dressed.

Insertion of the two Kirsehner wires into the maxilla

Each Kirschner wire passes through the skin of the face in the upper end of the nasolabial skin fold lateral to the ala of the nose and is driven into the bone of the maxilla in the direction of the centre of the palate. The point of the Kirschner wire should come to rest under the palatal mucosa. If it penetrates the mucosa it must be withdrawn until it is no longer seen or felt. The point of entry of the wire into the bone can be visualized, if two vertical stab incisions are made in the mouth at the gingiva-mucosal reflection, over the roots of the canine teeth, before it is pushed through the

skin. One must be aware of the variable anatomi- cal design of the bone of the inferior margin of the anterior nasal aperture. If teeth are present it is advisable that the Kirschner wire pass between the roots of the canine and lateral teeth at a point a third of the way down the root of the canine from its apex.

The Kirschner wire is generally directed at an angle of 45 ° to the horizontal and sagittal planes of the maxilla.

In the edentulous case the Kirschner wire is inserted in a similar manner.

Additional Kirschner Wires

When required, additional Kirschner wires are inserted into mobile fragments for their specific immobilization. This additional fixation is gener- ally required when a very unstable zygomatic component is present. To obtain the best purchase and control, this Kirschner wire should be driven into the bone from the front of the face.

Re-establishment of the Occlusion or the intermaxillary relationship

Prior to the final reduction of the facial fractures the mandible must be immobilized to the maxilla. This is carried out by using any of the recognised methods of immobilization but, if teeth are pre- sent, simple eyelet wiring is preferred. In the edentulous mouth, if the mandible is intact, the patient's own dentures are inserted to control the reduction.

The reduction and immobilization o] the facial fractures The upper section of the frame is locked to the two titanium pins and the lower section to the two Kirschner wires. The ends of the lower section of the frame are placed in close relationship to the vertical arms of the upper section. This design allows for an upward as well as antero-posterior movement of fragments during the manipulation. When the reduction of fragments is completed the two segments of the frame are lo&ed tightly together by means of universal clamps, which have been previously set in position.

Experiences Within the last 18 months this new fixation appli- ance for immobilisation of mobile parts of the

Fractures of the Middle Th i rd of the Facial Skeleton

Table 1 Analysis of Salient Features of First 17 Cases Treated.

131

Case rl'ype of injury or procedure Methods of immobilization Period of intermaxillary immobilization

1. Le Fort II[ fracture with very unstable Face frame for middle third fracture. 7 weeks (Fig. 2) left zygomatic component. Split palate. Additional Kirschner wire to support

Fracture of both condylar ne&s and left zygmnatic component. Eyelet wiring comminuted fracture of left body of and intermaxillary immobilization mandible

2. Le Fort Ill fracture with severely dis- Face frame and direct interosseous wir- Post-operative mobilization (Figs. 3-4) placed left zygomatic fragment. Gra& ing of left zygomatic fragment in of mandible for 24 hours

fracture left canine region of mandible fronto-zygomatic suture region. Eyelet and then immobilization for wiring with intermaxillary immobili- 3 weeks zation

3. Le Fort I osteotomy for "dish-faced" Face frame. Cap splinting for inter- Post-operative mobilization (Fig. 5) deformity and pseudo-prognathism maxillary immobilization for 24 hours and then immo-

in cleft pala|e case bilization for 2 weeks

4. Le Fort III fracture with left zygoma Face frame for middle third fracture. NIL grossly displaced and left eye dis- Lower Gunning Splint with circum- organised. Fractured symphysis of the ferential wiring for mandible mandible

5. Le Fort III fracture. Fractured sym- Face frame for middle third fracture. 5 weeks physis of the mandible Eyelet wiring with intermaxillary

immobilization

6. Le Fort III fracture with left zygoma Face frame for middle third fracture. 2 weeks comminuted and comminution of outer On left side Moule's pin inserted in half of left supraorbltal ridge. Left eye frontal sinus region along supra- disorganised. Crack fracture left body orbital ridge. Eyelet wiring with inter- of mandible maxillary immobilization

7. Le Fort III fracture with very unstable Face frame for middle third fracture. NIL right zygomatic component. Mandible Additional Kirschner wire to support intact right zygomatic component

8. Lc Fort I fracture with impaction. Face frame. Eyelet wiring with inter- NIL Mandible intact maxillary immobilization for reduction

9. Le Fort Ill fracture. Impacted maxilla, Face frame. Eyelet wiring and inter- Post-operative mobilization nasal complex and right zygoma, maxillary ilnmobilizatio n of mandible for 24 hours Fracture right eoronoid process of and then immobilization for mandible 3 days

10. Le Fort II fracture, impacted maxilla Face frame. Eyelet wiring and inter- NIL and nasal component. Mandible intact maxillary immobilization for reduction

1 I. Le Fort II fracture with split palate. Face frame. Eyelet wiring and inter- 7 days Impacted maxilla. Mandible intact maxillary immobilization

12. Le Fort III fracture. MandibIe intact Face frame. Eyelet wiring and inter- Post-operative mobilization maxillary immobilization of mandible for 24 hours

and then immobilization for 48 hours

13. Le Fort II fracture. Fracture left angle Face frame. Upper border wiring left 5 weeks and right condyle angle fracture of mandible and eyelet

wiring and intermaxillary immobilization

14. Le Fort I osteotomy for malunited Face frame. Eyelet wiring for inter- Post-operative mobilization fracture maxilla maxillary immobilization for 24 hours and then

immobilization 3 weeks

15. Lc Fort I fracture. Fracture of necks of Face frame. Upper Gunning Splint, NIL both condyles of mandible with minimal lower cap splint for reduction displacement

16. Le Fort III fracture. Mandible intact Face frame only. Reduction achieved NIL without any intermaxillary immo- bilization

17. Le Fort iII fracture. Mandible intact Face frame. Patient's own dentures used NIL to guide reduction of fractures

132 I. Smith

Fig. 2 This full face photograph illustrates the new method of immobilization. The photograph is of case 1, and was taken on the 5th post-operative day.

Fig. 3a A full face photograph of case 2 referred to in table 1. The photograph was taken on the 7th postoperative day.

Fig. 3b The profile photograph of case 2.

Fig. 4 The post-operative radiograph of case 2. The fracture at the left fronto-malar region has also been directly wired.

middle third of the facial skeleton was used. The method proved to be very satisfactory in our hands. In Table i our first 17 cases are briefly reported.

Discussion

This procedure provides a rigid immobilization of the maxillary segment and, should the man- dible be intact, it is possible at the conclusion of the operative procedure to release the inter- maxillary linkage without jeopardizing the oc- clusal relationship. This is of immense value if an obstruction to the cipated or does occur. If the links have been released they can be re-applied when the patient is fully concious or has made a reasonable post- operative recovery. Where the intermaxillary immobilization is retained, early mobilization of the intact mandible is possible, usually at the end of the second or third post-operative week. When the patient is edentulous and the mandible is intact, intermaxillary immobilization is avoided in the first instance. If intermaxillary immobilization is removed in the first instance or early during treatment, it is essential that the articulation of the teeth or the relationship of the edentulous jawsbeperiodically che&ed. Obviously when a severe mandibular fracture is associated with the middle third injury, inter- maxillary immobilization cannot be dispensed with.

Fractures of the Middle Third of the Facial Skeleton 133

Fig. 5 a Fig. 5 b Fig.5 c

Fig. 5 a-c A full faced pre-operative photograph of a patient with a "dish-face deformity" associated with a cleft lip and palate (case 3 in table 1). b) The full faced post-operative photograph of case 3 showing the face frame in position after Le Fort I osteotomy for advancement of maxilla, c) The profile photograph of case 3.

To date this method of treatment has proved most satisfactory. It has allowed for one-stage defini- tive treatment, and 23 patients who had sus- tained Le Fort I, I I or I I I fractures of the middle third of the facial skeleton have been treated by this method. This method of immobilization was also used for 4 patients who were treated for facial deformities which required Le Fort I maxillary osteotomies for their correction.

Within 24 hours of surgery all the patients were free of pain. None experienced more than slight discomfort while the apparatus was in position.

When the apparatus was removed all the Kirsch- ner wires and titanium screws were still so firmly embedded in the bone that a hand drill was re- quired to remove them.

In all but two cases the apparatus was removed without subjecting the patient to an anaesthetic. Neither electrical reactions nor bone infections were noted at any site where the Kirschner wires or screws were embedded in the bone.

In every case treated by this method the fractures were firmly united when the frame was removed on the 4th post-operative week.

Conclusion

This method of immobilization of fractures of tile middle third of the facial skeleton has proved to be of great value, and I and my associates have

used the technique almost exclusively during the past 18 months.

However, as with any method of treatment, diffi- culties do arise when additional or alternative means of treatment have to be sought.

If the pins and wires are firmly inserted into the bone and the fragments are correctly reduced, a foreward position of the fragments is maintained when the frame is locked in position. However it is essential at the conclusion of the operative procedure, when the anaesthetist's throat pack is removed, to closely inspect the occlusal relation- ship of the teeth. If there appears to be a slight shift the intermaxillary links must be reapplied and retained for a period of a few days, when the intact mandible is again mobilized for inspection. When fragments are firmly impacted and treat- ment has been delayed, it is preferable to use cast metal cap splints in conjunction with this tech- nique especially if difficulty is experienced in dis- impacting the fractured segments.

If a split palate is encountered and it is obvious that eyelet wiring with intermaxillary linkage will be incapable of closing the midline gap and holding the fragments, cast metal cap splints are used to provide the added stability.

It has been my impression that the whip action of the Kirschner wires on the maxilla produced a foreward leverage on the reduced nasal complex and thus provides it with added support.

134 S. R. Mektubjian

If the supraorbital r idge is f ractured in its outer aspect, the Moule pin can be inserted into the stable side of the rim in the region of the frontal sinus. Provided that the pin is correctly sited and angulated there is no danger of entry into the anterior fossa of the skull. Ent ry into the frontal sinus is without consequence. To insert the Moule pins into the tapped hole in the bone of the supra- orbital r idge it only requires a few slow turns of the hand dri l l to obtain a f i rm hold of the pin. W h e n the frame is being assembled the upper sec- tion should be kept as close as possible to the skin

of the face and should be placed beneath the anaesthetist 's cathether mouth.

Acknowledgement My thanks are due to Dr. M. Salmon, Superintendent of the Johannesburg General Hospital and to Dr. J. de W. Becket, Superintendent of W.E.N.E.L.A. Hospital for permission to publish, to my registrars, Dr. R. Lurie and Dr. P. Uys for their unfailing assistance and to the photographic department of the Department of Sur- gery, Medical School, for providing the photographic prints. Further information concerning the components of the face frame can be obtained frmn the author.

References Lewmt, B. A., R. M. Cook, MacFarlane: Experience

with the Levant Frame for Cranio Maxillary Fixa- tion. Brit. J. Oral Surg. 11 (1973) 30

Mackenzi, D. L.: The Royal Berkshire Hospital "Halo". Brit. J. Oral Surg. 8 (1971) 27

Dr. lan Smith, 103, Lancet Hall, ]eppe Street, Johannesburg, 2001, Transvaal, Republic of South A#ica

j . max.-fac. Surg. 2 (1974) 134-141 @ Georg Thierne Verlag, Stuttgart

A Method of Internal Suspension Fixation in Jaw Fractures - General Considerations

Sarkis Rupen Mektubjian

Institute of Emergency Care "N. I. Pirogov" (Direclor: P. Ko:ndova) Emergency Clinic of Neurosurgery (Head: Assist. Prof. M. Vanev) Sofia, Bulgaria

Summary In multiple trauma cases which are characteristic of modern living, definitive fixation of the jaw fractures is often postponed under the pretext that it is not a life-saving procedure. The main reasons that such an attitude has been adopted are the rather prolonged and relatively traumatic methods of reduction and fixation hitherto used. A procedure for internal suspen- sion fixation is described providing firm fixation of the reduced jaw fragments by means of an operation of short duration and minimum trauma.

Key-Words: Facial injuries; Fracture fixation.

Introduction The earliest possible definitive bone fixation is the ideal basic requirement in the t reatment of facial fractures. Due to the extensive mult iple

injuries which is characteristic of modern living, definitive fixation of the facial bones is often deferred on the ground that it is by no means urgent as a l i fe-saving procedure. Not infrequent- ly, it is postponed well beyond the 15th-20th post- in jury day. Such a policy is justified by the rather prolonged and relat ively t raumatic me- thods of reduction and fixation employed.

Everyday routine practice g radua l ly necessitated the development of a method which would enable the insti tution of prompt and a t raumat ic defini- tive fixation of the j aw fractures at the earliest moment in cases of maxi l lo- fac ia l t rauma often associated with l i fe- threatening t raumatic lesions of other organs and systems. The method sug- gested, owing to its short durat ion and la& of