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Appendix F

APPENDIX F

Treatment of Maxillofacial Injuries

(Extract from Manual of Therapy, European Theater of Operations)

A. Primary Surgical Treatment.

I. General Considerations.

1. A correlated plan of treatment, if carried out from the time the wound is incurred until definitive treatment is available, will greatly shorten the period of disability of patients with face and jaw injuries, and a larger number will be restored to approximately normal function and appearance than if haphazard methods are followed. Certain things should be done and others should not be done. Hence, attention to these points will save many lives and facilitate later treatment.

2. The use of local and systemic chemotherapy is indicated as for wounds of other parts of the body. This is particularly important in the treatment of massive wounds involving the floor of the mouth and those associated with compound fractures.

3. Primary care, points demanding special attention.

a. Control of hemorrhage.

b. Provision of adequate respiratory airway.

c. Temporary approximate reduction and fixation of maxillofacial fractures and adjustment of parts to anatomical position. (Relief of pain, treatment of shock, and other emergency measures as indicated.)

d. Early evacuation to a hospital for definitive treatment.

II. Specific Considerations.

1. Control of hemorrhage.

a. Control moderate hemorrhage by pressure from gauze compress and bandage.

b. Hemorrhage not controlled by pack and pressure will require clamps and ligature of the bleeding vessels. In case ligature is not available and clamp is left on, it should be included in the bandage and marked.

c. In severe hemorrhage, life may be saved by application of digital pressure to a bleeding vessel at a control point in its course, until a clamp and ligature can be applied.

d. DO NOT increase respiratory difficulty by the application of gauze compress and bandage. Bandages should not create backward pressure or traction distally on fractures of the mandible.

2. Provision of adequate respiratory airway.

a. Clear mouth and throat of tooth fragments, detached bone fragments, broken or dislodged dentures, and all foreign matter.

b. Insufficient respiratory airway can be improved by the insertion of a rubber tube through the nose or mouth to the nasopharynx.

c. Critical cases may require intra-tracheal tube.

d. Tracheotomy should be done promptly if more simple measures fail to provide an adequate airway. In some cases of massive injury about the jaw and pharynx, tracheotomy will be necessary as an emergency life saving measure.

e. In case of collapse of pharynx and floor of the mouth, or loss of control of the tongue, an airway can be maintained by holding the tongue forward. This can be accomplished by passing a suture through the tip for holding it forward. (In extreme emergency cases safety pins have been used to transfix the tip of the tongue.) Fractures of the superior maxillae frequently displace the loose structures downward and backward and definitely interfere with respiration. Bilateral comminuted fractures of the posterior part of the


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mandible may cause the chin segment to drop downward and backward, likewise causing respiratory interference. In either case, the front of the jaw may be held forward by a simple emergency splint.

(1) Material

Wooden tongue depressors, 4
Adhesive tape.
Bandage, 2-inch.
Ligature wire.

(2) Construction

Two tongue depressors are placed end to end and are held by two others overlapping them in the middle, all being bound together with adhesive tape.

(3) Application

(a) This unit is secured vertically in the frontal region with a circular bandage so that the lower end is projected in front of the mouth. The upper end is attached to the bandage in the occipital region with a piece of tape.

(b) A wire ligature is attached to the lower teeth or passed around the chin segment of the mandible, and the ends of the wire fastened to the lower end of the tongue depressor piece, either directly or with a rubber band.

(c) The spring of the tongue depressor piece or elastic traction effectively keeps the anterior segment of the mandible forward. Likewise in cases of backward displacement of the maxillae, forward traction can be obtained by attachment of the upper teeth to the apparatus.

3. Temporary approximate reduction and fixation of maxillo-facial fractures and adjustment of displaced parts to anatomical position.

a. Institute adequate measures for relief of pain and prevention of shock. Morphine should be administered cautiously to patients with respiratory difficulty and is contra-indicated for patients with associated cranial injuries.

b. Cleanse wound superficially, removing tooth fragments, detached bone particles and foreign matter.

c. Displaced parts should be gently adjusted to anatomical position and gauze compress and bandage applied. Avoid collapsing bone segments and prevent backward traction on the mandible.

d. Maxillary fractures and fractures of the adjacent facial bones should be gently supported by stable bandaging. In primary treatment, this stabilization can be improved by the application of gauze compresses and bandages used to control hemorrhage. It is essential to aid at re-establishing the former occlusion of the teeth, therefore all bandages applied should be supportive in this direction. Wire ligatures and suture material, if available, can be applied to the teeth of the same jaw across the line of fracture, to assist in stabilization of parts during evacuation. Multiple loop wiring, with intermaxillary elastic traction for reduction and stabilization of certain fractures, should be accomplished as early as time and facilities permit. Rigid intermaxillary fixation with wire is definitely contra-indicated in primary treatment for any case that might become nauseated or develop respiratory interference during evacuation. Edentulous cases require bandages that gently support the parts and avoid the tendency to collapse the segments. Dentures should be located, if possible, for use with adjustment and splinting of alveolar parts. These should always be transferred with the patient (even if broken).

e. Stabilization of parts is essential to avoid recurrent hemorrhage, reduce pain and prevent shock.

f. A stimulating dose of tetanus toxoid is indicated as for wounds of other parts of the body.

4. Evacuate patients to a hospital or station where definitive treatment can be provided early.

a. Ambulant or semi-ambulant patients with oral or pharyngeal wounds should travel sitting up, if possible.


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b. Litter patients should be placed in a comfortable position and prone (face down) so that there is no possibility of interference with respiratory airway or aspiration of fluids.

*    *    *    *    *    *    *

B. Definitive Surgical Treatment.

I. General Considerations.

1. Superficial wounds are classified as those wounds of the face in which there is no evidence of fracture of facial bones, or deep penetration. These wounds, when seen early, may be closed by primary suturing, provided they are relatively clean and can be thoroughly cleansed and carefully debrided. Severe maxillofacial wounds with loss of tissue, especially those resulting from gunshot, should not be closed by primary suturing. Specialized care should be instituted as early as personnel, time and facilities permit.

2. Anesthesia is seldom required for the initial care of maxillofacial injuries before evacuation to an installation where definitive surgical treatment can be accomplished. When an anesthetic is indicated, first consideration should be given to regional infiltration or nerve block anesthesia for surgical treatment of severe traumatic lesions about the face. General anesthesia may be necessary if trauma involves structures in the nose, mouth or pharynx. Maintenance of an airway and prevention of seepage of blood into the trachea is essential. The use of Pentothal [sodium] is hazardous and is contra-indicated in presence of shock. Inhalation anesthesia is indicated. Introduction of an endotracheal tube, either through the mouth or nose, as conditions dictate, is highly desirable. Maintenance of Trendelenburg position (10) will protect against seepage into the lung by promoting drainage of blood and secretions into the pharynx where they can easily be removed by suction. Insertion of wet packs into the pharynx is also indicated to establish a closed system. If extensive trauma within the mouth or pharynx is likely to be followed by edema or emphysema, it may be necessary to establish a tracheal stoma prior to surgical treatment of the primary lesion, and to use this avenue of approach for administration of the anesthetic by inhalation and subsequently for aspiration of excess secretions.

II. Specific Considerations.

1. Reduction and fixation of fractures and adjustment of parts to anatomical position.

a. Secure consultation and aid of dental surgeon if available.

b. Do not manipulate fractured fragments of maxillae in the presence of fractures of the base of the skull and accompanying injury of the brain until drainage of fluid has ceased and patient's condition approximates normal.

c. Final control of hemorrhage. Use small hemostats and fine ligatures. Ligate locally and not in course of the vessel and maintain maximum blood supply to the parts.

d. The wound should be cleansed thoroughly under the best surgical conditions. Remove all tooth fragments, foreign matter, detached particles of bone and dislodged teeth in line of fracture, since these are elements that invite infection. Do conservative debridement of soft tissues. Excise only tissue that is completely devitalized and tissue which obviously has no chance of survival. Protect nerves, vessels, ducts and glands. The use of small cutting needles and fine sutures placed near approximating skin edges will aid in prevention of suture scars. Skin sutures should be removed early.

e. Bone particles that still possess periosteal attachment should never be removed, since these small vital attachments may make all the difference between consolidation and new bone formation with restored function, and collapsed fragments with the attendant complications; even comminuted viable bone should be saved.

f. In cases of massive loss of substance, adjust soft tissue and restore torn flaps to normal position. Suture mucous membrane to skin edges to cover raw surfaces and to preserve skin and mucous membrane. Avoid closures under tension that produce overlapping of fractured ends of bone or collapse of bone fragments. Provide adequate dependent drainage to deep penetrating wounds, and especially those communicating with the mouth. Immediate suture is only advisable in superficial wounds and wounds that can receive proper care within a few hours after injury.


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g. Fractures of maxillae and mandible.

(1) Complete roentgenographic studies should be an integral part of definitive treatment.

(2) Aim at re-establishing the former occlusal relationship of the teeth, and ultimate restoration of dental function. Collapse of bone segments should be avoided in cases with loss of structure.

(4) The use of labial arch bars or wiring of the teeth of the same jaw across the line of fracture may be indicated for stabilization during evacuation.

(5) Rigid intermaxillary fixation of the lower teeth to the upper should not be used prior to unattended travel. Intermaxillary elastic traction may be used safely for this stabilization since the mouth can be opened in case of nausea and the elastic bands easily removed or tension regulated as indicated.

(6) Immobilization of fractures can be accomplished by the application of intramaxillary multiple loop wires and intermaxillary elastics, for reduction and fixation, when sufficient teeth remain in each jaw. The application of a vertical circular bandage with mild buccal elastic traction may be indicated for auxiliary support of maxillary fractures. (This bandage, made of plastic material, will eliminate the collapsing tendency of ordinary bandage.)

(7) Sectional dental splints of proper design and construction may be used to advantage in the treatment of complicated cases for immobilization when limited function is desirable.

(8) Edentulous fractures require the skillful application of supporting bandages to maintain the parts in proper position, without causing collapse of segments or interference with airway. Dentures are particularly important as they can often be used in connection with supporting bandages or circumferential wiring.

(9) Another method of reduction and retention of edentulous cases, or those with displaced edentulous fragments, is afforded by the application of the extra-oral skeletal pin and bar fracture appliance.

2. Every effort should be made to provide trained personnel for the care of maxillofacial injuries throughout the combat area. Adequate life-saving measures and early treatment are necessary to insure the casualties getting to the hospitals of the next echelon for more definitive treatment. The execution of a well-correlated plan of treatment throughout will not only save life but result in many casualties being returned to duty after a minimum period of hospitalization. End results are of great concern and usually said to be directly proportionate to the nature and character of the early treatment received. Patients with maxillofacial injuries, requiring extended care and reconstructive surgery, should be transferred to the Zone of Interior when the treatment has progressed to such a stage that evacuation can be safely accomplished.

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