2. A history of the management of maxillofacial injuries. The development of intermaxillary fixation.

Although trauma has been with us since the dawn of time, it is only recently that we have been able to approach it scientifically. For this reason, the original reports of treatment do not necessarily follow any logical pattern, amounting to a series of case reports contained within the literature from the earliest pre-Christian times to Egypt in 2000 B.C. when a dislocation of the mandible as well as a fractured mandible were described. Hippocrates described reduction and fixation of mandibular fractures with strips of calico glued to the skin immediately adjacent to the fracture and laced together over the scalp. The ancient physicians of Alexandria and Rome also mentioned the ligation of teeth using fine gold wire or Carthugian leather strips glued to the skin. These principles laid down by Hippocrates extended through the literature as far as the first millennium. It was probably Salicetti in 1474 in Bologna who first described the simple expedient of ligating the teeth of the lower jaw to the corresponding teeth of the upper jaw to affect immobilisation of a fracture. Previously, it was recognised that within 3 weeks, the union of jaw fractures would be complete. The 16th and 17th centuries saw the introduction of gunpowder and the first reports of gunshot wounds. It was Ambroise Par to whom we must attribute the first significant change in the management of facial wounds via copious irrigation and the application of balms rather than the use of cauterisation. His particular care of facial wounds and his application of what he described as a dry suture facilitated secondary healing of these wounds, particularly treatment of compound wounds. The next milestone was achieved by Richard Wiseman, a surgeon in the latter part of the 17th century, who described the management of maxillo-facial injuries. As well as describing the signs and symptoms of a fracture, he also described many individual cases, including a child with a comminuted fracture of the cribriform process of the ethmoid. He also described the disturbance in occlusion and related protrusion or recession of the lower jaw and the destruction of soft tissues in association with these injuries. These astute clinical observations were added to those studies of anatomy and physiology at the Italian schools of Bologna and Padua in the early 18th century. Together, they laid the foundation for serious advances in the systematic management of jaw injuries. Chopont & Desault (1780) were the first to describe a different type of approach by introducing the concept of a dental splint that consisted of a shallow trough of iron, inverted over the occlusal surface of the lower teeth, which were protected with cork on lead plates. A bar projected from the front incisor region, bent at right angles, and fastened by thumbscrews to a submandibular plate of sheet iron. Movement of the fragments was thus prevented by compression between the occlusal surfaces of the teeth and the lower border of the mandible. Variations of this principle were employed during the next 100 years and were introduced subsequently into Germany by Rutenik in 1799, who further stabilised the head harness, into England by Lonsdale in 1833, and into Holland by Hartigs & Grebber (1840); however, each was a modification of the original principle that still found employment after World War II for the fixation of certain

epithelial inlay splints in the edentulous mandible. Different forms of supportive bandaging were introduced, accompanied by wedges of cork between the occlusal surfaces of the teeth to keep the teeth apart and facilitate feeding. Earlier in 1825, Naysmith co-operated with Robert Liston to provide a cast, gold cap splint. This splint was soldered together and affixed to the teeth to prevent the displacement of the mandible in a mandibulectomy case until the majority of the forces of soft tissue contraction had dissipated. The discovery of anaesthesia allowed for a significant advance when Fauchard in France and Buck in the USA began to use direct intraosseous silver wires. Results were variable due to the development of sepsis and consequent sequestration. A variation by Wheelhouse involved driving silver pins through each piece of bone and winding silk thread around each pin in a figure eight to approximate the bone ends. War has always provided opportunities for surgical developments, and so it was with the American Civil War of 1861-1865 and the Franco-Prussian War of 1870-1871, in quick succession, that a large proportion of mandibular fractures arose from horse kicks or falls onto the chin. In 1861, Gunning produced his splint, although he was probably unaware that it followed the same principle as the one developed by Naysmith in 1825 for use by the surgeon Liston. From dental impressions, a monobloc construction was produced and bound to the jaws by a bandage that passed under the chin and over the vertex of the skull. Teeth in the line of fracture were extracted. Later in the war (1864), Bean, who treated many fractures, made a significant advance by sectioning dental models of the jaws and carefully realigning them before constructing a Gunning type of splint. The first reports of swaged metal splints appeared simultaneously by Allport in America and Hayward in London. Allport s gold splints were swaged to leave the occlusal and incisive edges free, and, having correctly aligned them, the splints were soldered together. Soft gutta-percha was used to attach the splints to the teeth. Hayward covered the occlusal surfaces of the teeth and used soft gutta-percha for attachment. A separate submental gutta-percha splint was placed in position and a bandage or rubber band was used to connect it to two arms projecting from the splint and curving backward around the commissures of the mouth. Despite further modifications by Kingsley, all these splints were essentially modifications of the original splint by Chopart and Desault in 1780. The inherent weakness in all these splints was the lack of secure fixation to the jaws, and various attempts were made to overcome this problem. Initial descriptions by Hamilton Adams in 1871 used fine nuts and bolts that passed through the interdental spaces. Some 3 years later, Moon, in London used fine interdental wires to achieve the same result. It was at about this same time, that Woodward, in the USA, melted down silver coins (silver and copper) to produce opencast, metal cap splints, attached to the crowns of the teeth by small screws. The two splints were connected to one another by lugs, and through the means of eyelets soldered to them, the jaws could be wired together, thus giving IMF. Although a significant advance, the very complicated nature of the process and the lack of a cementing medium for attaching the splints to the teeth meant that these splints did not catch on rapidly. However, attention is now shifting to the improved accuracy of reduction provided by focusing on the occlusion. During the Franco-Prussian War, Hammond described the use of arch bars on both the lingual and buccal aspects that were fixed to the teeth by fine interdental eyelet wires. This process was adapted for both the wiring of the arch bars and the continuous loop method. At the same time, Suerson, in Berlin, who had been chiefly employing the Gunning principles, but when treating malunions, conceived of using separate splints for each section and of driving wedges of hickory wood of ever-increasing

thicknesses between these splints, which gradually realigned the arches. This seems to be the first account of an attempt to realign the displaced arches.

In 1887, Gilmer returned to an almost forgotten technique, the direct wiring of teeth. This resurrection of an old principle, suitably modified, was a significant advance and became increasingly important as orthodontic techniques became adapted by surgeons for the treatment of fractures. Angle applied his principles of fixed anchorage points and individual bands cemented to selected teeth in each jaw as a means to restore a correctly aligned dentition. So now, for the first time, we see science applied to the management of these injuries. This, together with the huge advances in surgery occasioned by the introduction of anesthesia, the institution of antiseptic and later aseptic techniques, and the introduction of X-rays for clinical purposes by Roentgen in 1895, changed the scene dramatically. Other significant advances that followed at that time include the reconstructive work of Abb, Estlander, and Thiersch; the first treatment of fractured zygomas by Matas (1896) and the midface by Bouvet in 1901; Le Fort s work on fracture patterns; and the surgical approaches to the zygoma of Lothrop (1906), Keen (1909), and Manwaring (1913), which led up to the casualties of the 1914-1918 war in Europe. The scale of these injuries, 26 million casualties of the 56 million individuals involved in armed conflict, was due largely to trench warfare and the destructive nature of high-energy explosives that rendered the face prone to more severe injury than had been seen previously. However, the sound principles laid down at the turn of the century did not undergo any radical changes; rather, there were a series of refinements in techniques that often followed the application of orthodontic principles to splint construction. Circumferential wires were used in some cases, Gunning-type splints were used in others (especially edentulous cases), and both open- and closed-cast silver cap splints in dentate patients were used to a greater extent than had been used previously. Fresh cases were treated by sectioning the models, restoring the occlusion in the laboratory, and forcing the segments into the splints at the time of reduction and immobilisation. In cases where treatment was delayed, reduction was achieved using orthodontic techniques. The use of interdental eyelet wires was demonstrated by Ivy (1914) as an effective way to provide IMF in the dentate patient and was increasingly practised. Replacement of both hard and soft tissues had reached a remarkable degree of sophistication with surgeons developing ingenious techniques to achieve outstanding results, but sepsis, leading to gangrene, hospital-based infections, as well as other general infections, all contributed to the high level of morbidity and mortality of that time. Lister, followed by the first chemotherapeutic agent, prontosil, made great strides to treat these severe complications. There followed certain, specific improvements in the surgical care of facial fractures. Notable among these was the development at East Grinstead of sectional splints, one for each segment, linked together by intraorally located, locking plates, which underwent later modification to be located extraorally. Middle third fracture management also underwent improvements where cheek wires, first developed by Federspiel, were used to fix the posterior region of the maxilla to the plaster of-Paris headcap. By the end of World War II in 1945, there was an increasing realisation that when bone ends are brought into close proximity with one another, more rapid healing occurs. With the advent of antibiotics, a greater use of direct approaches to the fracture sites led to the use of direct interosseous bone wiring or osteosynthesis. Such wires were generally applied to either the upper or the lower borders of the mandible and the fronto-zygomatic suture, all solid pieces of bone. During this time, pin fixation was used, particularly in the treatment of compound, comminuted, and frequently infected jaw fractures. Despite a reduction in its use, this concept was retained and used by Fordyce in the Box-Frame technique. A variety of pins were used from the fine, threaded, Clouston-Walker pin, modified for the East Grinstead pattern, and MacGregor pins, to the coarse, threaded, tapered, Moule pin. It was not until the Vietnam War that American forces came to use

biphasic pin fixation, popularised by Morris (1949), and external pin fixation again became the treatment method of choice. With the advent of the antibiotic era, recognition of the value of direct fixation became widely accepted in orthopaedic practice and was adapted for maxillo-facial purposes. Initially, direct bone wiring was used to control 1) the edentulous posterior fragment; 2) multiple fragments in the edentulous mandible; and 3) the grossly comminuted mandibular fragments and the lower border of the mandible where the upper jaw was already secured by one of the conventional methods of fixation but where the lower border remained inadequately reduced and immobilised. Although the use of bone plates had previously been attempted (Konig, 1905; Lambotte, 1907; Lane, 1914; Sherman, 1924), it was not until Roberts (1964) and Battersby (1967) introduced stainless steel, vitallium monocortical miniplates that the present use of surgery was established. The lack of malleability of these initial miniplates limited their usefulness for they broke as soon as any attempt was made to bend them. The initial introduction of malleable stainless steel followed by titanium enabled Champy (1976, 1978) to develop a scientific basis for the application of miniplates in the treatment of mandibular fractures. Inevitably, numerous clinicians and manufacturers provided their own modifications, but the principles of application remain unchanged. Bioresorbable plates, made initially of polylactic acid and, more recently, of a combination of this and other suitable materials, were developed (Bos, 1983; Rozema, 1991; Suuronen, 1992). Their biodegradation tends to be accompanied by a significant collection of fluid beneath the skin. The compression osteosynthesis techniques used by orthopaedic surgeons have been applied to maxillo-facial surgery by Luhr (1968, 1972) and Becker & Machtens (1970). The use of specially designed taps and matching screws allowed both cortices to be engaged that, when combined with the specially designed plates, produced firm opposition of the fractured bone ends under compression. This process results in primary bone healing by direct osteoblastic activity within the fracture as opposed to secondary bone healing through callus formation. Intramedullary pinning and the use of titanium as well as nonmetallic mesh, particularly in the treatment of malunions and fractures of the edentulous mandible, all have important applications.