The Maxillofacial Trauma: Evolution of Treatment Through Ages

Standing in the present moment, it helps to look back to ponder how far we have come, while gauging the road ahead: as in life, so in our specialty. Talking about mandibular fractures, ancient writings of Castiglioni (600−500 B.C.), suggest that Etruscans were aware of the art of monomaxillary gold wiring to treat fractures of the mandible. ¹ Hippocrates (460–375 B.C.) cautioned against bandaging a fractured jaw improperly as this could do more harm than good. ²

From a translation of the Corpus Hippocraticum in the “Treatise on joints” by Tallmadge, the use of gold wire or in the absence of that, linen thread fastening of multiple teeth together in monomaxillary fashion seems to be prevalent in his time. ³ Saliceto’s Cirurgia (1474) was probably the first of documents available which mentioned the use of maxillo-mandibular fixation (MMF) with the use of a linen thread and a silk thread twisted together and waxed up for the use in interlacing between teeth.^3,4 However, years later revival of MMF by wiring was credited to T.L.Gilmer in 1887.^4,5

In the late 18th century and early 19th century, intermaxillary splints were used with double gutters made up of cork, wood, metal, or horn. Later, these were lined by gutta-percha, modeling compound, or plaster of Paris to receive indentation of teeth. Some forms of extraoral-intraoral splints were also in use which added chin support. T.B. Gunning was the first to use vulcanite to fractured jaws in 1861. ³ Norman W. Kingsley (1829−1913) reported the use of interdental splints after taking an impression of the fractured segments. Modifications of these were widely used in world war I. The use of circumferential wiring was first credited to Jean-Baptiste-Baudens (1840). In the course of time, G.V. Black in the US combined the use of circumferential wiring and vulcanite splints. ³

Before Lister’s introduction of aseptic surgery between 1860 and 1870, closed reduction was the mainstay of treatment. ⁶ With the development of anesthesia and antibiotic drugs, ushering in an era of open reduction and internal fixation became possible.

Some of the earliest reports of mandibular fracture open treatment are by Gurdon Buck (1846) using iron trans-osseous wire and Kinloch (1858) using silver wire. A few decades were yet to pass before the earliest designs of plates and screws came into use in orthopedic surgery (Hansmann in 1886) and then alloy compositions were altered to enhance the mechanical properties, first suggested by Sherman and the Lambotte brothers. ⁶

Robert Danis in 1949 published “Theorie et Pratique de L’ Osteosyntheses.” In this classic, he put forward 3 principles of internal fixation.^7,8 (1) Immobilization causes regressive changes in musculoskeletal tissues and causes “fracture disease” and hence should be avoided. (2) Anatomic reduction to optimally restore functional requirements. (3) Union of the fragments without formation of the visible callus so that “internal welding” could occur. He also gave the principle of compression osteogenesis for the first time.

In the mid-1950s, 15 Swiss surgeons founded “Arbeitsgemeinschaft für Osteosynthesefragen” (AO) and that was the start of fracture treatment as we know today, with the key ­principles of anatomic reduction, rigid internal fixation, atraumatic technique and pain-free active mobilization. ⁹

After a short period of compression plating, in 1973 Michelet et al. ¹⁰ and in 1978, Champy et al. ¹¹ described a method of monocortical fixation of fracture mandible, using miniaturized plates.

With the evidence of the success of these mini plates, AO changed its principle of “rigid internal fixation” to “functionally stable fixation.” ¹² Since then, a better understanding of biomechanical demands through finite element analyses has given rise to geometric plates, and yet, as the classic sequential studies on mandibular angle fracture by Ellis ¹³ have shown, nothing comes above the in vivo, good quality clinical studies.

Due to concerns over metal corrosion debris, plate-palpability, thermal sensitivity, and the need for 2nd surgery to remove metallic plates, bio-resorbable systems were invented. Despite the good performance in providing mechanical ­stability, due to the high cost of the implants, these are not routine, at least in the developing countries. ¹⁴

While we await big leaps of invention like clinically applicable and economic options from tissue engineering science for the defect fractures, the least we can do is to generate good quality studies for nuances in current-day fracture ­treatment and make our practices evidence-based. A recent bibliometric analysis has suggested that out of the top 100 cited systemic reviews and meta-analyses in our specialty, only 10 are pertaining to maxillofacial trauma. ¹⁵ It is reasonable to believe that baby steps in the direction of merging the art of surgery with the science of it would have a major impact on the patient care that we provide!