Mandibular fractures can be beautifully demonstrated by computer tomography (CT) with 3D reconstruction. The exact location and type of fracture can be well known before any surgery is contemplated. A nice example is shown below of a patient who suffered trauma to the left jaw resulting in a fracture of the ramus. The exquisite anatomy of the fracture is clearly seen and the surgeon has a clear roadmap on how to approach the surgery.
This is in stark contrast to the situation on the missionary field where most diagnoses are made clinically since patients cannot afford diagnostic tests. This reminds me of a patient I treated in Nigeria about 2 years ago. He was a young man that was turning a winch with a handle. The handle snapped back and hit him on the chin. His father brought him to the Nigerian Christian Hospital. The boy's lower jaw was clearly fractured at the symphysis (midline). In addition, the front two teeth were fractured off with a piece of the maxillary alveolar ridge. We had no xray facilities, so I thought the best course of action was to send them to the University Hospital several hours away. A little while later, the Chief Medical Officer at the Nigerian Christian Hospital gently pulled me aside and told me that my plan was bad. He said the patient and family would never go to the University since they had no money. They would just go home and and the jaw would never heal correctly. He encouraged me to do the repair myself. I looked at the father and son and realized the CMO was correct. Father and son were poorly dressed and clearly poor farmers. They had no money so I would have to do the job. As Admiral Farragut stated over 200 years ago, "Damn the torpedos, full speed ahead".
We took the boy to surgery. Unfortunately, I had no drill, drill bits or wire! We finally found a drill bit (from the carpenter) and a handrill (which I had purchased at Home Depot) and some old wire suture. After a fair bit of struggling, we were able to wire the broken jaw pieces back together. I then gently hammered the front teeth and bone back into place in the maxilla and wired his jaw closed. He would have liquids for the next 4 weeks. The fractures all healed without any complications.
This is what life on the mission field is about. You do what you have to do, with whatever you have to do it. I wouldn't try this on your kitchen table, however.
