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The New Zealand Dental Services

CHAPTER 31 — Maxillo-Facial Injuries

page 375

Maxillo-Facial Injuries

THE treatment of maxillo-facial injuries requires a close cooperation between the medical and dental professions for, apart from the usual surgical procedures connected with gross tissue destruction and bone fractures, there are special factors in injuries to the face and jaws that are intimately associated with the teeth. It can in fact be said that the key to a successful restoration of facial harmony often lies in establishing correct relationship of the jaws, the one to the other. There is a dental problem here requiring a high degree of manipulative skill and an intimate knowledge of dental prosthesis. The infinite variety of injuries ranging from the simple mandibular fracture to the destruction of half the face makes it impossible to label a case as medical or dental. The best results are got by working as a team in which the plastic surgeon, dental surgeon, dental mechanic and many others play their parts.

In the First World War when casualties of this type were numerous, such a team was working at Sidcup in England under a New Zealand plastic surgeon and dentist, Major H. P. Pickerill, NZMC. These New Zealanders were associated at Sidcup with similar teams from England and other Dominions. At an early stage of the 1939–45 War an organisation for the treatment of maxillo-facial injuries was developed in England but, unlike the arrangements at Sidcup, was decentralised. Throughout England and Scotland nine or ten centres were set up under the Emergency Medical Service (EMS) scheme. These were controlled by the Ministry of Health and catered for civilian as well as service casualties. Sir Harold Gillies, a New Zealander practising in England, was appointed consultant adviser in plastic surgery to this organisation and Mr Kelsey Fry, MC, consultant adviser in dental surgery.

It was not until October 1940, when the Second Echelon of New Zealand troops was on duty in England, that the Director-General of Medical Services in New Zealand instructed its ADMS to discuss with Sir Harold Gillies the possibility of forming a New Zealand plastic surgery and maxillo-facial injuries unit. As a result, two medical officers and one dental officer stayed behind when the Second Echelon left England in January 1941. The dental officer page 376 was Captain F. R. Brebner, NZDC. In the meantime Major J. J. Brownlee, NZMC,1 was sent from New Zealand to join them and to become plastic surgeon in charge of the unit when it was formed. In December 1940 Captain G. H. Gilbert, NZDC,2 and in June 1941 Captain W. R. Hamilton, NZDC,3 accompanied by two mechanics each, also went to England.

At the time these arrangements were being made the New Zealand Expeditionary Force in the Middle East had not been welded into a division and had not taken part in campaigns where many maxillo-facial injuries could have been expected. The intention was that medical and dental officers and dental mechanics would be trained in England for periods up to twelve months. Those who started earliest were to be available for despatch to the Middle East as soon as the Division went into action, but it was hoped that the others would be able to finish their twelve months' training before becoming attached to field and base medical establishments according to future developments.

The plastic surgery and maxillo-facial hospitals to which the New Zealanders were attached were at Basingstoke, East Grinstead and St. Albans. They worked under the permanent dental staff. The officers were allotted cases for which they became responsible and the mechanics, after making splints and appliances for hypothetical cases, took their full share in making them for cases under treatment. An account of the methods of treatment and of the types of cases seen in these hospitals is too technical for inclusion in this history, but the reader who is interested is referred to an article by Captain Gilbert published in the New Zealand Dental Journal of October 1942.

While these men were training in England, 2 NZ General Hospital at Helwan was receiving its quota of casualties from General Wavell's offensive which drove the Italians out of the Western Desert and Cyrenaica. Amongst these casualties were a number of British and Australian maxillo-facial cases. Major E. B. Reilly was dental officer of this hospital and his management of them, including some of the utmost severity and involvement, fully earned for him the congratulations he received from the Australian Director of Medical Services who visited the hospital at the end of the campaign.

1 Lt-Col J. J. Brownlee; Christchurch; born Christchurch, 2 Sep 1902; surgeon; plastic surgery specialist, 2 NZEF, Jan 1941–Jul 1942; OC Plastic Surgical Unit, Burwood, Apr 1943–Sep 1944.

2 Maj G. H. Gilbert; Christchurch; born Wellington, 20 Nov 1908; dental surgeon; dental officer, 2 NZEF, Dec 1940–Mar 1943; Plastic Surgical Unit, Burwood, Apr 1943–Jun 1944.

3 Maj W. R. Hamilton; Christchurch; born Dunedin, 4 Apr 1910; dental surgeon.

page 377

When the New Zealand Division suffered its first battle casualties in Greece and Crete, those with jaw and face injuries were treated in the field ambulances. Because of the complications of the evacuation this treatment was in most cases the last received before they reached base hospitals in Egypt or, as prisoners of war, hospitals in Athens. It is difficult to estimate the incidence of jaw and face injuries from this campaign as many did not survive. Of those who reached Egypt, only a proportion arrived at 2 General Hospital at Helwan, which was the only New Zealand hospital then operating in Egypt. The others went to British hospitals. At 2 General Hospital Major Reilly again carried out all the dental treatment. Although only five were admitted to his hospital from Greece and Crete, he was kept busy with many non-battle injuries of this type, several of them from English, South African and Australian units. The maxillo-facial cases taken prisoner in Greece and Crete eventually arrived at the reconstituted 5 Australian General Hospital in Athens, to which were attached four NZDC officers captured with the New Zealand Mobile Dental Section.1 One of these, Captain P. Noakes, did excellent work under difficult conditions, a fact that was revealed when these patients were repatriated after their time in the prison camps.

In October 1941 Captain Brebner and Sergeant V. Mullany,2 having completed their training in England, arrived in Egypt and were attached to 2 General Hospital. The hospital was at Baggush as an advanced field hospital for the Libyan campaign of November-December 1941. There were few maxillo-facial injuries from the New Zealand Division but one case treated by Major F. Hutter, NZMC,3 and Captain Brebner may be said to have made history. It was probably the first time that the pin fixation method of immobilising a fractured mandible was used under field conditions and, what is more, the appliance was improvised. This method of treatment had only recently been introduced in the English maxillo-facial centres and an efficient form of appliance for the actual fixation of the intra-osseous pins was still in the developmental stage. Briefly, the method was to insert two sharp-pointed pins through the skin surface into each of the bony fragments, the pins being set at a converging angle to prevent displacement. The fracture was then reduced and the bones held in alignment by rigidly joining the ends of the pins by a system of connecting rods. Under normal conditions the apparatus was already made as part of

1 See pp. 1845.

2 Sgt V. Mullany; Christchurch; born Palmerston North, 30 Jul 1914; dental mechanic.

3 Lt-Col F. L. Hutter; Wellington; born Auckland, 6 Feb 1910; surgeon; 5 Fd Amb 1940; 6 Fd Amb 1941–44; surgeon in Gen Hosps, 1944–45.

page 378 standard equipment. The bar connecting the pins was easily adjusted by a system of universal joints, making it applicable to any case. This apparatus had not yet been issued.

When Major Hutter and Captain Brebner were confronted with a casualty with a shattered mandible whose general condition was rapidly deteriorating through pain, sepsis and the inability to take nourishment, they decided that unless the mandible could be quickly immobilised the patient had little chance of living. Ordinary methods of treatment such as splints or wiring were impracticable and the only hope was to use the pin fixation method. If there was no apparatus provided in the equipment, then they must make their own. With the help of a nearby Royal Air Force repair unit, and from the metal parts of a wrecked aeroplane, an appliance was quickly made. It differed from the universally adjustable type, being made to order for that particular case. Cardboard patterns were cut to indicate the estimated reduced position of the bony fragments and the appliance was made so as to fix the position of the pins according to this pattern. The operation of inserting the pins and getting a satisfactory reduction was extremely difficult but the result was good. The jaw was immobilised in position with immediate relief to the patient, so that in a few days his general condition began to improve and his life was no longer in danger. Subsequently this patient needed a bone graft, but it is unlikely that he would have survived to receive it but for the success of the improvised appliance. The full details of this case, together with two treated by Major Reilly, are recorded in the New Zealand Dental Journal of January 1943.

When 2 NZ General Hospital went to Baggush it was replaced at Helwan by 1 NZ General Hospital, with Major Reilly as maxillo-facial dental officer. Most of the cases treated at this hospital at that time were non-battle casualties. It was already becoming noticeable that this war was not producing as many jaw and face injuries as the previous war. New Zealand was estimating the establishments required to treat these injuries on the figures provided by the First World War. It was time to review the whole situation and to decide if perhaps the specialist service was being made too large. The training of medical and dental specialists withdrew officers from general duties from which they could ill be spared. It was essential to know if the small number of maxillo-facial injuries was a true indication of what would happen in the future. A reason was sought for the disparity between the figures in the two wars. The conclusion reached was that there were two. The first was the change from trench to mobile warfare as, in the former, the head was a more common site for wounds. The second was the increased destructive page 379 force of missiles, resulting in a larger number of jaw and face injuries being fatal.

The delicacy of the decision was briefly this. Should many be withdrawn from general duties to concentrate on a specialty which could employ only a few or should those few partially train enough of their colleagues to ensure a satisfactory chain of treatment in the force? The latter decision prevailed, and although only four dental officers received full courses of training, a large number of others were intimately associated with maxillo-facial treatment in its various stages.

In January 1942 Captain Gilbert and Sergeant L. St. J. Morgan1 arrived in Egypt from England, becoming attached to 1 General Hospital. Major Reilly relinquished the duties of maxillo-facial officer and became general oral surgeon to the hospital. In addition to their specialist duties, these two officers carried out routine dental treatment of all patients and staff. The plastic surgeon at the hospital was Captain W. M. Manchester, NZMC,2 who had just completed twelve months' training in England.

There were then two fully trained teams of New Zealanders working in the Middle East. Equipment was excellent, Captain Gilbert having brought with him from England enough to provide facilities almost equal to those in the dental departments of the hospitals in which he trained. This included four sets of the pin fixation appliance, now being produced by a surgical manufacturing firm in England. Captain Gilbert records that his first impression on taking over from Major Reilly was a sense of appreciation of the excellent work already done by the medical and dental officers of the Division, both in field ambulances and at base hospitals, without the advantages of special training or specialist facilities.

The establishment of maxillo-facial injury teams was the nucleus of the treatment of this class of case, but the team could not function properly without the intelligent co-operation of medical and dental units in the field. The team was usually in a hospital many miles from the battle area. Cases needed treatment before reaching the hospital. Apart from the obvious need to get the patient to the hospital alive and reasonably comfortable, the nature of the treatment in the early stages largely influenced the degree of success to be expected at the hands of the specialists. The importance of this had been emphasised in England and a memorandum had been sent out by the Army Council in an attempt to standardise this preliminary treatment as far as possible. This preliminary treatment

1 Sgt L. St J. Morgan; Matamata; born England, 1 Aug 1906; journalist.

2 Lt-Col W. M. Manchester; Auckland; born Waimate, 31 Oct 1913; medical practitioner; RMO 22 Bn 1940; 1 Gen Hosp 1942–43; asst surgeon, Plastic Surgical Unit, Burwood, 1944; OC Plastic Surgical Unit, 1944–47.

page 380 was mostly carried out in field ambulances and the Casualty Clearing Station. To emphasise further the importance of this treatment, the ADDS arranged for Captain Gilbert to instruct the dental officers concerned in all phases of the work and to enlarge on the memorandum from the Army Council. The field ambulances and the Casualty Clearing Station also had special equipment added to their panniers.

In line with his policy of interchangeability of all officers within the Corps, the ADDS then asked Captain Gilbert to prepare a course of instruction so that all dental officers would know what to do in the field and would have a proper appreciation of the course of treatment at the maxillo-facial centre. Demonstration models and diagrams were prepared to illustrate the various methods of fixation. Case histories with X-rays and photographs were assembled from actual cases seen in England. The course was given twice on occasions when it was possible to assemble the officers at the Base, so that eventually all dental officers with the 2 NZEF attended. Each course took three and a half days and included a discussion by Major Reilly of the cases he had treated and by Captain Manchester of the work of a plastic surgeon.

Fully organised plastic surgical and maxillo-facial units were attached to two British hospitals in Egypt at Alexandria and Helio-polis. These were responsible for the care of all British and, if necessary, any other maxillo-facial casualties, and had been extremely busy following the first and second Libyan campaigns and those in Greece and Crete. With the establishment of the New Zealand teams it was intended that, as far as possible, New Zealand casualties would in future be treated in New Zealand hospitals. Consequently, following the battles at Minqar Qaim and Alamein between June and October 1942, the number treated at 1 General Hospital was much higher than those following the earlier campaigns. The dental officers with the field ambulances fully justified the care taken in their training. For instance, during the battle of Alamein, Captain N. M. Gleeson, NZDC, of 4 Field Ambulance treated and evacuated a number of very serious cases.

In the meantime more New Zealanders were training in England. Major Brownlee, NZMC, the senior plastic surgeon of the New Zealand Military Forces, and Captain W. R. Hamilton, NZDC, with two mechanics left England for New Zealand in 1942. Captain Hamilton with one of the mechanics later joined 3 NZ Division in New Caledonia, forming the dental part of a maxillo-facial injuries section with that force.

New Zealand was proposing to form a plastic surgical and maxillo-facial unit in New Zealand, similar to those in England, to page 381 receive all cases evacuated from the Middle East for completion of treatment and as a centre for the more immediate treatment of any major cases from 3 Division or the RNZAF in the Pacific. Major Brownlee was promoted to lieutenant-colonel and given the task of forming the unit, and in January 1943 Major Gilbert returned from the Middle East to work with him. This left Major Brebner as the dental specialist in the Middle East. Before taking up his appointment, Major Gilbert toured New Zealand on the instructions of the DDS to lecture to as many NZDC officers as possible.

The unit was established at Burwood Hospital, Christchurch, in April 1943. One ward was allotted for the purpose and extensive additions were made to accommodate an operating theatre, dental department, X-ray plant and other amenities. The dental surgery and laboratory were equipped to the same high standard as in all permanent NZDC sections in New Zealand. As Major Gilbert had not been able to bring any equipment with him, some had to be ordered from England although most of it was soon procurable in New Zealand. By the time the unit was established there was an accumulation of cases, mostly plastic surgical but some needing maxillo-facial reconstruction, especially bone grafts.

In maxillo-facial work it is possible to lay down certain fundamental principles but no instructions could possibly cover the infinite variety of injuries. Much must therefore be left to the ingenuity of the individual operator. During the later stages of the North African campaign the lines of communication were so long that it might be some time before a maxillo-facial casualty could reach a specialist centre. More had to be left to the dental officer on the spot, and in many cases it called for nice judgment at a Main Dressing Station or Casualty Clearing Station whether treatment should be extensive or merely palliative. It is greatly to the credit of the dental officers at these stations that, without the benefit of specialist training, their application to the task brought such good results. Some indeed seemed to have a natural aptitude for this class of work and it is a curious coincidence that the dental officer attached to the New Zealand Casualty Clearing Station, through whose hands passed a great number of casualties, not only from the New Zealand Division but from many English units, was Captain E. P. Pickerill, NZDC, son of the surgeon who was in charge of Sidcup in the 1914–18 War. His article on ‘The Treatment of Maxillo-facial Casualties in a CCS’ and one by Captain N. E. Wickham, NZDC, on ‘The Treatment of Maxillo-facial Casualties in the Field’, both of which appeared in the New Zealand Dental Journal of April 1945, were so concise and comprehensive that the ADDS included page 382 them as an appendix to his ‘Notes and Instructions to Dental Officers’ as a guide to all dental officers serving in the field.

The work of Captain P. Noakes, NZDC, at 5 Australian Hospital in Athens has already been mentioned. The work of another NZDC officer, Captain J. T. Dodgshun, at a prison camp in Germany also deserves mention. He was placed in charge of a prisoner-of-war hospital at Stalag IXC. This hospital became a centre for Allied prisoner-of-war maxillo-facial injuries, most of those treated being British and American Air Force casualties and, later, Army personnel from the Western Front. He had had no special training and there were very limited facilities with which to work. There was no equipment to make cast-metal splints, but for cases requiring this form of treatment he made splints of acrylic resin, a material with which, at that time, he would not have been familiar. He mastered the art of intermaxillary wiring, of which he could have had little if any experience as a student or civilian practitioner. In addition to this he made many prostheses of acrylic resin to retain the shape of eye sockets. The thirty-four cases he treated up to the cessation of hostilities included a wide variety of injuries. His work is recorded in an article, ‘Jaw Injuries in a Prisoner of War Hospital’, published in the New Zealand Dental Journal of October 1945.

Every officer of the NZDC who was in a position where he might be called on to render emergency or preliminary treatment for jaw injuries, whether overseas or in New Zealand, was equipped with a field maxillo-facial outfit. This applied to dental officers attached to field ambulances, Casualty Clearing Station, operational air squadrons, flying training schools, warships and hospital ships. The number of maxillo-facial casualties among New Zealand troops was proportionally small and cannot be accurately assessed for the future, but it is reasonable to assume that there will always be a need for an organisation to treat this type of casualty. The increased lethal power of modern weapons makes more of these cases fatal, but the greater use of mechanical transport at higher and higher speeds must leave in its train many injuries of this type.

The experience of the 1939–45 War shows that it does not need many highly trained specialists to handle the work, but that it is essential that every dental officer should have at least a working knowledge of the science. The average dentist in civilian practice has no opportunity to see this type of work and might go through the whole of his career without treating a single case. It is from these men that the dental officers of the future will be drawn, and it is unlikely that without encouragement they will devote much time from their busy practices to give more than a cursory thought to a subject of academic interest only. The good results in wartime page 383 of the lectures and demonstrations in the Middle East and New Zealand suggest that a similar series might find receptive soil in peacetime. A stimulation of interest in the subject, while there are still enough dental officers with practical experience in the field and at base hospitals to speak with authority, would be an investment for the Corps of the future. The dental officer in time of war is primarily a dentist in uniform, holding his commission by virtue of his professional knowledge. It should not therefore be necessary to instruct him in any branch of that knowledge to fit him for the position after he has been appointed to it. By reason of the rare incidence of maxillo-facial injuries in the average civilian practice, this subject becomes the exception, and if the Dental Corps wants fully trained dental officers, it is its responsibility to fill that want. It can open the door to that fascinating subject or, at least, put a little oil on the hinges, with the reasonable chance that some will be interested enough in its attractions to study further. The time to train for war is in peace.