British Journal of Oral and Maxillofacial Surgery 44 (2006) 222228

Mandibular fractures: Historical perspective

R. Mukerji a , G. Mukerji b , M. McGurk a,
a b

Department of Oral and Maxillofacial Surgery, Guys and St. Thomas Hospital, Salivary Gland Service, Floor 23, Guys Tower, London SE1 9RT, UK Hammersmith Hospital and Imperial College, London, UK

Accepted 24 June 2005 Available online 19 August 2005

Abstract The principles of the treatment of mandibular fractures have changed recently, although the objective of re-establishing the occlusion and masticatory function remains the same. Splinting of teeth is an old way of immobilising fractures but the advent of modern biomaterials has changed clinical practice towards plating the bone and early restoration of function. We present a brief historical overview of techniques and systems that have been used for stabilisation of mandibular fractures. 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Mandibular fractures; Historical review

Introduction It is important to view historical reports in the context of their time. Historical insight improves understanding of current techniques and provides the basis for the development of new methods. From the time of Hippocrates, physicians have described many different techniques for treating mandibular fractures, the principle of which has always been repositioning and immobilisation of the bony fragments. However, during the past 50 years, perfection of anaesthetic and radiographic methods, introduction of antibiotics, specially designed instruments, and advances in biomaterials have allowed maxillofacial surgeons to improve outcomes while reducing morbidity. In this paper, we review the evolution of the management of mandibular fractures from the Persian period to the present day.

Luxor in 1862 and later translated by Breasted.1 The Egyptians attitude to mandibular fractures was rather pessimistic: If thou examinest a man having a fracture in his mandible, thou shouldst place thy hand upon it . . . and nd that fracture crepitating under thy ngers, thou shouldst say concerning him: One having a fracture in his mandible, over which a wound has been inicted, thou will a fever gain from it. An ailment not to be treated. Death usually followed, presumably caused by infection. However, the documents show that simple fractures of the jaw were treated by bandages, obtained from the embalmer, and soaked in honey and white of egg, while wounds were treated by the application of fresh meat on the rst day, a method which may well have introduced tissue enzymes and thromboplastins without, one hopes, too many bacteria. Historically, medicine (healing) and religion have always been entwined. In the Hellenic period, temples to Asklepios were set up and the secular assistants to the priests, known as Asklepiadae, helped provide medical treatment. To one of these assistants in the year 460 bc on the island of Cos, was born a son, Hippocrates. He looked at medical problems

The pre-Christian era The rst description of mandibular fractures dates to the 17th century bc in the Edwin Smith papyrus, bought by Smith in

Corresponding author. Tel.: +44 207 188 4348; fax: +44 207 188 4360. E-mail address: mark.mcgurk@kcl.ac.uk (M. McGurk).

0266-4356/$ see front matter 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2005.06.023

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from a more practical and mechanistic perspective, relying less on religious explanations. Hippocrates not only devised the technique of reducing a dislocated mandible, which still carries his name, but also taught methods of immobilising a fractured mandible. The ends of the fracture were reduced by hand and the fracture site was immobilised by gold or linen threads tied around the adjacent teeth. In addition to this intraoral immobilisation, he recommended extraoral xation by strips of Carthaginian leather glued to the skin, the ends of which were tied over the skull (Interestingly, the barrel bandage was still in use two centuries later.). According to Hippocrates, the fracture healed within 20 days when using this method of xation, provided that no infection developed.2

using complicated bandaging and bamboo splints covered with a mixture of our and glue that were applied under the chin to immobilise the fractures.3

The 17th and 18th centuries The association between medicine and religion extended into the Christian era, but when the Pope in 1163 ruled that any operation involving the shedding of blood was incompatible with the priestly ofce, the barbers took over the practice of rudimentary surgery. So from the Middle Ages to the early 1700s, much dental treatment was provided by so-called barber surgeons. These jacks-of-all-trades would not only extract teeth, treat facial fractures, and undertake minor surgery, but they also cut hair, applied leeches, and embalmed corpses.4 During this period (12th to early 18th century), the barber surgeons used the classical treatment of fractures. After manually resetting the fractured jaw, ensuring that the normal occlusion was maintained and the teeth adjacent to the fracture line were joined by ligatures, the mandible was immobilised by bandages. Various modications of bandages were used to immobilise the lower jaw by binding it to the upper jaw by a bandage that passed under the chin and over the head.5 It was prevented from slipping by another bandage carried over and around the occiput (Fig. 1). The 18th century saw a more scientic approach to medicine as a result of advances in the knowledge of anatomical and physiological processes. The era of scientic dentistry was ushered in by the publication of a book in 1728 by Pierre Fauchard, entitled Trait de chirurgie dentaire.6 e He was the rst to describe a comprehensive system for the practice of dentistry including basic oral anatomy and function, operative and restorative techniques, and construction of dentures. He is credited with being the Father of modern dentistry. Although Fauchard did not make any

The early medieval period During the period of the Roman Empire (23 bc410 ad) few if any true advances were made in the treatment of mandibular injuries, and reliance was placed upon the traditional Hippocratic methods. The Romans emulated Greek medical thought; the Roman encyclopedist Aulus Cornelius Celsus collected Greek and Roman medical thought in a series of volumes entitled Artes. Celsus addressed the treatment of fractures of the jaw in the eighth volume.1 In general, he adhered to the treatment advocated by the Corpus Hippocraticum: The fragments are repositioned using two ngers, then tie together with horsehair the two adjacent teeth, or if these are loose, tie them to teeth further away. Taking the Greek example further, Celsus advocated a ligature for xation of the fracture. Postoperative treatment included rubbing the injury with wine, oil, or our. He forbade his patients to speak and told them to live exclusively on liquid food for several days. About 500 ad, the Indian surgeon Sushruta wrote a treatise on operations. He recommended treating fractured jaws by

Fig. 1. Bandages to immobilise the lower jaw: Garretsons (left) and Hamiltons (right) (reprinted from Stimson5 ).

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special contribution to the treatment of fractures of the jaw, the impetus that he gave to the development of dental prostheses stimulated others to devise techniques for the control of the fragments of the dentate jaw other than by the use of simple ligation of the teeth and support from a bandage. As might be expected, the simple ligatures used to bind around the teeth were unable to hold the fragments of jaw in a rigid position, so the fracture was unstable. Bunon sought improved stability when, in 1743, he used a carved ivory block as a dental splint to which he tied all lower teeth by threads.7 In 1779, Chopart and Desault described a simple dental splint, essentially a shallow trough of iron laid over the lower occlusal table which was clamped down to the lower border of the mandible by an external screw device (Fig. 2).8 Variations of this principle were employed for a long time, being introduced into Germany by Rutenick in 1799, who applied further stabilisation by a head harness attached to a helmet by ribbons.9

The 19th and 20th centuries At the turn of the 19th century, there was a gradual shift in the management of fractures of the jaw away from general surgeons to dental surgeons, because the management of fractures depended on manipulating the dentition. Modern dental materials facilitated the construction of dental splints. These were the domains of the dental surgeon. The work has subsequently remained the remit of the dentally based specialties. Many renements were introduced by improving intraoral and extraoral splints or the use of either trans-mandibular or circum-mandibular wire xation to immobilise the mandibular fracture directly or indirectly. External xation often caused infection and the risk of malocclusion. In 1826, Rodgers did one of the rst open reductions. He inserted wire sutures in a case of pseudarthrosis of the humerus.2 Baudens is credited with being the pioneer of wiring mandibular fractures, and as early as 18402 he used circumferential wires to immobilise an oblique fracture. Soon after (1847), Buck applied wire sutures directly to the fractured bone by drilling holes in adjacent segments and wiring them together.10 Modications of this technique by using two double wires (R se) and the gure-of-eight wire o suture (Raas) improved stability,2 but before the advent of antibiotics few intraoral wounds healed without infection. Up to this time, all fractures of the jaw were reduced manually, without the aid of anaesthesia as an outpatient procedure. The introduction of anaesthesia by Dr. Horace Wells in 1844 revolutionised the practice of surgery.11 Speed was no longer of paramount importance and a degree of nesse could be introduced with improved results. This also applied to fractures of the jaw.

Fig. 2. Apparatus to immobilise a fracture mandible according to Chopart and Desault (1779) (reprinted from Rowe10 ).

Fig. 3. Kingsleys splint (top) and applied (bottom), 1855 (from Stimson5 ).

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Fig. 4. The Gunning splint (1866) (reprinted from Siegert2 ).

In 1855, Hamilton introduced the gutta-percha splint that was prepared in the patients mouth after reduction of the fracture. This splint enjoyed wide application, particularly during the American Civil War.10 Kingsley devised a splint, Kingsleys apparatus (Fig. 3), with attached bars by which the splint and the jaw could be bound rmly together with an outside bandage passing from one bar to the other underneath the chin.5 In 1858, Hayward developed a metal splint for severely dislocated fractures, the splint being adjusted to the individual needs on the basis of a plaster model of the jaws.12 This was a new development. A cast was made of the lower jaw, it was sectioned through the fracture site and the dental occlusion realigned. A splint was made to the new occlusion and covered the surface of the teeth. The fragments of the jaw were forced into the splint, so effectively reducing the fracture.

In 1866, Thomas Gunning designed the Gunning splint for Mr. William Seward, the Secretary of State to Abraham Lincoln.13 Seward had bilateral fractures of the body after falling out of a carriage. The splint was a single piece of vulcanite with a space for eating (Fig. 4). Screws were used to attach the splint to the hard palate and the mandible. A modied form of the Gunning splint is still used today. In 1871, London dentist Gurnell Hammond developed a wire ligature splint for immobilisation of the mandible.14 An impression was taken of the teeth and cast in stone. The displaced segments were realigned on the stone model and then a heavy iron wire was adapted to the teeth on the model. The bar was subsequently wired to the patients natural teeth, so pulling the misaligned fragments into line. The basic technique is still used today in the form of arch bars. In 1887, Thomas L. Gilmer reintroduced intermaxillary xation (a technique that had been forgotten for centuries) and the use of arch bars for mandibular fractures.10 His technique is still superior to other methods of xation in certain circumstances such as communited fractures and fractures of an atrophic mandible. However, the drawback of his technique is that it can be uncomfortable, and paintogether with the change in diet from solid to liquidcan lead to loss of weight and poor nutrition. Dr. Angle (1890) introduced an alternative to wiring the segments of the jaw. It consisted of banding teeth on either side of the fracture, and then bound in the bands together by wire to immobilise the fractureAngles apparatus (Fig. 5a). Angles method of xation of a broken lower jaw to an intact one (intermaxillary xation) was effected by placing bands on the teeth of the upper and lower jaw and around the short arms xed upon these bands wrapping a wire that holds them together, so using the upper jaw as a splint (Fig. 5b).10 Hippocrates said: War is the only proper school for a surgeon and much impetus to the improved management of facial fractures came with the mobilisation of whole nations for the First and Second World Wars. Trench warfare resulted

Fig. 5. Angles apparatus (a) and Angles intermaxillary xation (b) (from Stimson5 ).

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Fig. 6. Amex casque, designed by American Expeditionary Forces (World War I) (reprinted from Strother,20 copyright (2003), with permission from the American Association of Oral and Maxillofacial Surgeons).

Fig. 7. Fixateur externe developed by Grace George Ginestet in 1936 (reprinted from Hausamen,14 copyright (2001), with permission from the European Association for Craniomaxillofacial Surgeons).

in extensive maxillofacial injuries in thousands of soldiers. Military surgeons were forced to improvise in devising appliances for their patients and often created splints from coins, telephone wire, or meat tins. The Amex casque (Fig. 6) designed for the American Expeditionary Forces, became popular with French and British military surgeons.15 It had an adjustable steel band, tting around the circumference of the head, with adjustable cranial bands and an adjustable perpendicular rod and horizontal face bow. This appliance accomplished xation of either soft tissue or bone fragments and was used for many patients with injuries of the head and jaw. Dr. Varaztad H. Kazanjian, the chief dental ofcer at Harvard University was sent to England to assist the British in caring for injured soldiers in the First World War.3 He established a treatment plan for previously unmanageable maxillofacial injuries by wiring together small fragments of shattered jaw bone, and construction of special splints and internal vulcanised rubber supports that prevented the face from contracting until surgeons were in a position to graft bone and skin on to the damaged areas. Because of the extraordinary success of his techniques, British journalists dubbed Kazanjian the miracle man of the Western front. Kazanjian not only created a unique treatment for maxillofacial fractures, he also was a pioneer in the eld of modern reconstructive surgery. During the next few decades, there were many variations of splinting and techniques of intermaxillary xation, most notable by Robert H. Ivy (1922).10 He modied the technique of intermaxillary xation by creating a loop (eyelet) in the

wire ligature, which later became popular and was known as the Ivy loop. Although the rst percutaneous nailing of fractured long bones was by Parkhill as early as 1897,16 the use of Kirschner wires to treat mandibular fractures was published only in 1932.2 After restoration of normal occlusion, the fractured fragments were xed with a pin inserted transcutaneously. The xateur externe developed by the Ginestet, 1936 (Fig. 7), became popular in the management of complex facial injuries encountered in the 19391945 war and was in common use during the period of the Vietnam War.14

Development of osteosynthesis Modern traumatology started with the development of osteosynthesis, which was a major step forward in craniomaxillofacial surgery. Before its advent, most mandibular fractures were treated either by approximate xation using internal stainless steel wires, external xation using rigid metal pins, or custom-made silver cap splints (cast metal covering of all the teeth in the arch). The rst osteosynthesis plate was used by the British surgeon Sir William Lane over 100 years ago.17 The idea was in advance of its times, because the technology for plates to be biocompatible and the problem of sepsis had rst to be overcome. It was not until 1943 that Bigelow described screws and bars made of vitalliuman alloy of cobalt, chrome, and molybdenumfor use in the management of mandibular fractures.18 It was only in the late 1960s (when Luhr19 (Fig. 8a) and Perren et al.20 developed plates with

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Fig. 8. Osteosynthesis plate introduced by Hans Luhr19 (a). Miniplates developed by Champy and Lodde21 (b) (reprinted from Hausamen,14 copyright (2001), with permission from the European Association for Cranio-Maxillofacial Surgeons).

cone-shaped or spherical screw heads and compression holes that were congruent in shape and initiated their large-scale production) that the way was paved for osteosynthesis to be generally accepted in the treatment of facial fractures. Pauwels reported that the most favourable site of internal xation of a fractured bone was where the muscular tensile forces were at their greatest. Champy and Lodde in the early 1970s applied this tension band principle (also referred to as Champys principle) to the mandible in mathematical, biomechanical, and clinical studies.21 The rst plates were still bulky, and were designed exclusively for use in mandibular fractures. Miniplate osteosynthesis was rst introduced by Michelet et al. in 1973,22 and further developed by Champy and Lodde in 1975 (Fig. 8b).21 Spiessl introduced the lag-screw technique of osteosynthesis in1974.23 These screws had threads on the distal end and a smooth shank at the proximal end which allowed compression of the segments between the outer and inner components. During the following two decades a large number of modications of plates were described,2426 which led to the present use of osteosynthesis. In the recent times, Ellis has done extensive work on non-compression, monocortical plates for mandibular fractures, particularly those of the condyle and angle.27 Today, many different systems are available, ranging from the heavy compression plates for mandibular reconstruction to low prole plates for midfacial xation. The thickness of plates ranges from 0.5 to 3.0 mm and are made either of stainless steel, titanium, or vitallium. Recently, biodegradable, self-reinforced polylactide plates and screws have been used for the internal xation of fractures of the mandible with good results.28

Odontological Society in October 1899 that he had treated numerous fractures and never seen a case where there was any internal or external wound except at the fracture site.29 He reported that dental surgeons were never called upon to stitch a wound or to arrest undue haemorrhage. This contrasts with the injuries sustained in high-speed road trafc crashes of today. Nevertheless, many facial fractures are still caused by interpersonal violence and can be considered simple.30 External appliances xed to a head cap and semi-rigid immobilisation by wire suspensions that are cumbersome to the patient and entail long period of immobilisation have been superseded. These simple but crude techniques should not be deprecated because they are effective and can be relied on when modern facilities are not available. The improved results are derived from a better scientic approach to the biomechanics underlying the function of the jaw, and the tailoring of new techniques and biomaterials to these principles. It has also been made possible by the general advances, with control of infection and improved surgical instruments.

Conclusion The treatment of fractures of the jaw has a long history, from ancient Egypt to the present. Todays oral and maxillofacial surgeons are recipients of knowledge acquired from many surgeons through the ages, including Hippocrates, Kazanjian, and Lane. In the 18th and 19th centuries, fractures were treated quite successfully in outpatients. During that period the potential for sepsis was ever-present and access to anaesthesia limited, so treatment was conservative; the teeth were simply repositioned (without anaesthetic) using bandages and dental splints to hold them in alignment. Today, this work is undertaken in a more sophisticated way under general anaesthesia. The ability to control infection together with the advent of new biomaterials has revolutionised treatment. Now open reduction is the norm and tiny titanium plates are used to immobilise fragments of the jaw. Morbidity of the procedure is low with the advantage that the patient returns

Reection In reecting on the evolution in technique through the 19th century to today, one needs to appreciate that the type of fracture was different then from now. In 1895, the fractures were relatively simple. Dr. F. Weisse reported to the New York

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R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222228 15. Strother EA. Maxillofacial surgery in World War I: the role of the dentists and surgeons. J Oral Maxillofac Surg 2003;61:94350. 16. Parkhill C. New apparatus for xation of bones after resection and in fractures with tendency to displacement. Trans Am Surg Assoc 1897;15:2516. 17. Lane W. Some remarks on the treatment of fractures. Br Med J 1895;1:861. Quoted by Siegert and Weerda2 . 18. Bigelow H. Vitallium bone screws and appliances for treatment of fracture of mandible. J Oral Surg 1943;1:131. 19. Luhr H. Zur stabilen Osteosynthese bei Unterkieferfrakturen. Dtsch Zahn rztl Z 1968;23:754. a 20. Perren SMRM, Steinemann S, Mueller ME, Allg wer M. A dynamic o compression plate. Acta Orthop Scand 1969;125(Suppl. I):29. 21. Champy M, Lodde JP. Mandibular synthesis. Placement of the synthesis as a function of mandibular stress. Rev Stomatol Chir Maxillofac 1976;77:9716. 22. Michelet FX, Dessus B, Benoit JP, Moll A. Mandibular osteosynthesis without blocking by screwed miniature stellite plates. Rev Stomatol Chir Maxillofac 1973;74:23945. 23. Niederdellmann H, Schilli W, Duker J, Akuamoa-Boateng E. Osteosynthesis of mandibular fractures using lag screws. Int J Oral Surg 1976;5:11721. 24. Beal GLJ. Ost osynth se mandibulaire. Rev Stomatol (Paris) e e 1955;56:424. 25. Robinson M, Yoon C. The L splint for the fractured mandible: a new principle of plating. J Oral Surg Anesth Hosp Dent Serv 1963;21:3959. 26. Hoffer OAP. Behandlung von Unterkieferbr chen mit Metallpl ttchen. u a Dtsch Zahn rztl Z 1961;16:807. a 27. Ellis III E. Treatment methods for fractures of the mandibular angle. J Craniomaxillofac Trauma 1996;2:2836. 28. Ylikontiola L, Sundqvuist K, Sandor GK, Tormala P, Ashammakhi N. Self-reinforced bioresorbable poly-l/dl-lactide [SR-P(l/dl)LA] 70/30 miniplates and miniscrews are reliable for xation of anterior mandibular fractures: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:3127. 29. Weisse FD. Fractures of the maxillae. Dental Cosmo 1898:18896. 30. Van Beek GJ, Merkx CA. Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral Maxillofac Surg 1999;28:4248.

to normal function within days of treatment. But low morbidity comes at a price of expensive materials and the need for inpatient hospital facilities. References
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