92 
FRACTURES OF BONES OF THE FACE. 
separated, and muscular contraction prevent their being replaced in 
position. 
Diagnosis of fractures of the malar, caused by external violence, is 
only difficult when much swelling exists. If not due to cellulitis, to the 
piesence of new growths, or disease of the superior maxillary sinus, such 
swelling should arouse suspicion of a fracture, especially if there be any 
consideiable difficulty in mastication. Where the superior maxillary 
sinus is laid open, or the zygomatic ridge injured, doubt can no longer 
exist. Damage to the alveoli of the upper molars, or extensive tearing 
of muscular insertions, give rise to difficulty in feeding. Subcutaneous 
fiactuies of the malar bone, which are of rare occurrence, unite easily, 
and compound fractures only cause difficulty when the aveoli of teeth 
are exposed, and purulent alveolar periostitis results. 
Treatment of subcutaneous fractures merely requires regulation of diet 
m many cases. When involving both sides, fracture of the premaxilla 
may result in the incisors and the bone being displaced downwards and 
backwards or in the bone being split and the fragments displaced 
laterally. In the former case a stout baton of wood can be inserted into 
the mouth and used as a lever to replace the bone and teeth, which 
then usually remain in position on account of the opposing row of teeth 
suppoiting them; in the latter case a shallow groove is formed in the 
comer incisors of each side and a thick copper wire passed several times 
around the six incisor teeth, supporting them and holding the two 
bones together. Compound fractures heal most rapidly under antiseptic 
treatment. Should purulent alveolar periostitis supervene, the 
affected teeth must be removed. In endeavouring to replace the frag¬ 
ments dislocated by the pull of the muscles of mastication, it has been 
recommended first to perform myotomy. But this entails the danger of 
making a simple subcutaneous fracture into a compound one ; while, if 
already compound, exfoliation of bone may ensue. Further treatment 
is legulated by general principles. Reference may be made to fractures 
of the frontal bone, and diseases of the superior maxillary sinus. 
Figs. 54 and 55 illustrate a plastic operation performed by Bayer to 
lemedy loss of skin in two carriage horses which had run away and 
damaged the bone to such an extent as to necessitate removal of con¬ 
siderable portions. The skin having become adherent to the mucous 
lining of the sinus, it was necessary to dissect considerable flaps in order 
to cover the defects. The parts were carefully shaved and disinfected, 
and a slender paring removed from the edges of the wound to ensure 
fresh surfaces for union. In the first case an incision was carried from 
d successively to points /, g, and h, and the flap dissected free from sub¬ 
jacent tissues, leaving it connected with the rest of the skin only at ah. 
I lie pi obligation to/and the large size of the flap were necessitated by 
