Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIII: Maxillofacial Wounds and Injuries

Fracture Management

United States Department of Defense
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After conservative debridement of bone fragments has been completed, any remaining exposed bone must be covered by soft tissue. A mandibular stump can be covered by suturing mucous membrane to the skin edge. If the oral cavity has not been excluded by watertight closure, the fracture site must be drained to the exterior for 2 - 5 days.

Only teeth which are completely loose or fractured teeth with exposed pulp should be removed. Firmly embedded teeth are left in situ, even if they are near fracture lines. Damaged teeth are useful for immobilization of fractures. Residual molar teeth in otherwise edentulous jaws are especially valuable for fixation. Although dead, carious, or loose teeth may cause infection, they should not be disturbed at this time.

Immobilization of the jaws is necessary for accurate reestablishment of occlusion as well as early union of fractures. It also facilitates the healing of soft-tissue wounds, limits the spread of infection, and prevents deformity.

Several methods of immobilization of the jaws are practical, as follows:

1. Application of commercially-produced archbars to the labial and buccal aspect of the maxillary and mandibular teeth with simple circumdental wires (Figure 30). Fixation is then achieved either with intermaxillary wires or elastics or both.
2. Any one of several other commonly described techniques; i.e., eyelet loops, continuous loops, and Risdon wiring.
3. In the edentulous situation, the patient's dentures may be fixed by circumferential wires in the mandible and by peralveolar pins or wires in the maxilla. The dentures may then be used as anchorage for intermaxillary fixation. If dentures are not available, other options, depending upon the situation and preferences of the surgeon, include open reduction and rigid fixation with a bone plate or similar device, or the application of an external biphase splint. Construction of individualized dental splints is seldom possible or indicated in a combat zone hospital.
4. When portions of the mandible have been avulsed, the external biphase splint is an excellent and expedient technique by which the mandibular segments may be retained in good position and alignment during healing. Other types of preformed or adaptable plating and bridging devices may be used, but they require larger wound exposure and entail a greater risk of infection and therefore are not recommended for use in the combat zone.
5. Multiple and grossly comminuted fractures are most often best managed by closed reduction techniques.  

Figure 30.

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