Facial trauma

Facial trauma

1393/3/5

Isfahan university of medical sciences

M: SONBOLESTAN MD

33

PRIMARY SURVEY

A. Airway and C-spine control

B. Breathing and ventilation

C. Circulation and hemorrhage control

D. Disability

E. Exposure

M. Monitor

LIFE-THREATENING CHEST INJURY

1. Airway obstruction

2. Tension pneumothorax

3. Open pneumothorax

4. Massive hemothorax

5. Pericardiac tamponade

6. Flail chest combined pulmonary

contusion

SECURE AIRWAY

Assist airway

Oral airway, nasal airway, LMA Endotracheal intubation

Oral, nasal Surgical airway

Cricothyroidotomy

Tracheostomy

LIFE-THREATENING HEAD INJURY

Intracranial hemorrhage

Epidural hematoma, subdural hematoma,

intracerebral hematoma, subarachnoid

hematoma Diffuse axonal injury Management

a. Evacuation of hematoma

b. Decrease IICP and mass effect

c. Maintain cerebral perfusion

I I C P

Symptoms

Headache, vomiting, consciousness

change Signs

Increase BP, decrease HR & PR

papilledema Neurological findings

Focal sign, pupil size and light reflex

WOUND CARE

1. Copious irrigation

2. Remove foreign body

3. Antiseptic solution

4. Adequate debridement

5. Primary / Delayed suture

LIFE-THREATENING ABDOMINAL INJURY

1. Liver laceration

2. Spleen laceration

3. Large vessel injury

4. Pelvic fracture

TRAUMATIC SHOCK

1. Hypovolemic shock

2. Neurogenic shock

3. Cardiogenic shock

4. Septic shock

FLUID RESUSCITATION1. Access

Two large bore IV catheter

2. Fluid

Crystalloid, colloid, blood component

3. Amount

a. Bolus: 2 liter for adults

20 ml/ kg for child

b. maintain amount based on urine output

THREATENING EXTREMITY INJURY

1. Femoral fracture

2. Multiple fracture

3. Nerve, vessel, muscle and soft

tissue injury

THERMAL INJURY

1. Major burn

2. High-voltage electric injury

3. Inhalation injury

4. Chemical burn

ACUTE ABDOMEN

Differential diagnosis

Surgical abdomen / medical abdomen Pain history

Onset, location, intensity, duration,

radiation, quality, associated symptoms Symptoms sequence

Urological Emergency

Painful conditions Bleeding conditions Trauma conditions Others

REEVALUATION

Time interval Same personnel Vital signs Laboratory examination Early suspicion Early consultation

MEDICAL ETHICS

Treat a person not a disease Treat a patient as your family Be patient to a patient’s complaint Be kind and more smile Careful explanation

1919

Frontal sinus fractureFrontal sinus fracture

Frontal sinusFrontal sinus

Drains into nasal cavity via fronto-nasal ductDrains into nasal cavity via fronto-nasal duct

An air filled cavity lined by ciliated respiratory epithelium encased in the frontal bone

2020

Extent of the injuryExtent of the injury::

Anterior tableAnterior table

Posterior tablePosterior table

Associated injuries: Associated injuries: mid-face or head mid-face or head injuries e.g.injuries e.g.

Le Fort II, IIILe Fort II, III NOENOE Neuralgic insultsNeuralgic insults Ocular injuriesOcular injuries

2121

DiagnosisDiagnosis

Clinical examinationClinical examination

Radiographical Radiographical evaluationevaluation

Occipitomental viewsOccipitomental views Lateral skull viewLateral skull view CT scanCT scan

2222

Classification of fracturesClassification of fractures

Anterior table fractureAnterior table fracture LinearLinear DisplacedDisplaced

Posterior table fracturePosterior table fracture LinearLinear DisplacedDisplaced

Outflow tract injury Outflow tract injury (naso-lacrimal duct)(naso-lacrimal duct)

2323

Surgical managementSurgical management

Intranasal cannulationIntranasal cannulation

Frontal sinus trephinationFrontal sinus trephination

Osteoplastic flap Osteoplastic flap

Sinus ablation Sinus ablation (obliteration)(obliteration)

Cranialization Cranialization

Reduction and fixationReduction and fixation

2424

Reduction and fixationReduction and fixation

Surgical approaches:Surgical approaches:

Site of penetrating injurySite of penetrating injury

Coronal approachCoronal approach

2525

Sinus ablation Sinus ablation (obliteration)(obliteration)

FatFat Muscle and Muscle and

fasciafascia BoneBone Alloplastic Alloplastic

materialsmaterials

2626

FixationFixation WiresWires PlatingPlating

2727

Nasal fracturesNasal fractures

AnatomyAnatomy Midline central facial Midline central facial

structure that fulfills both structure that fulfills both cosmetic and functional cosmetic and functional purposespurposes

Formed by union of rigid Formed by union of rigid and flexible strutsand flexible struts

2 rectangle-shaped 2 rectangle-shaped nasal bonenasal bone

ULCs, LLCs and ULCs, LLCs and midline septal midline septal cartilagecartilage

2828

Classification of injuriesClassification of injuries Low energy injuriesLow energy injuriesSimple injury caused by low velocity trauma (simple noncomminuted)Simple injury caused by low velocity trauma (simple noncomminuted)

High energy injuriesHigh energy injuriesSevere injury with comminution of nasal facial Skelton due to higher Severe injury with comminution of nasal facial Skelton due to higher

amount of energyamount of energy

Patterns of injury

•Lateral injury (from the side)•Sagittal injury (from the front)•Inferior injury (from below)

2929

TreatmentTreatment Low energy injuriesLow energy injuries Reduction (close Reduction (close

manipulation, open reduction) manipulation, open reduction) and stabilizationand stabilization

Nasal packingNasal packing

External nasal splintExternal nasal splint

Adjunct septoplastyAdjunct septoplasty

Postoperative carePostoperative care

3030

Complex injuriesComplex injuries Immediate measures:Immediate measures:

Extra and intranasal examinationExtra and intranasal examination Identification of extra and intranasal Identification of extra and intranasal

lacerationslacerations Identification and control of site Identification and control of site

bleedingbleeding Surgical procedures:Surgical procedures:

Open septal proceduresOpen septal procedures Open nasal proceduresOpen nasal procedures Open rhinoplastyOpen rhinoplasty Open-sky “H” techniqueOpen-sky “H” technique

Nasal fractures

Nasal bone fractures Nasal aperture fractures

Nasal bone

Nasal bone fractures

Nasal aperture fracture

Types of aperture fractures

3636

Nasal-orbital ethmoid Nasal-orbital ethmoid injuriesinjuries

They represent a wide spectrum of injuriesThey represent a wide spectrum of injuries

Simple nasal fracture with involvementOf orbital bones

Grossly comminuted and compound naso-orbital ethmoid fracture involving the base

of skull with significant displacement

3737

DiagnosisDiagnosis

Clinical examination:Clinical examination: Obliterating swellingObliterating swelling Canthus detachmentCanthus detachment Lacrimal apparatus damageLacrimal apparatus damage Deformity of nasal bridgeDeformity of nasal bridge CSF leakCSF leak

Radiographical examinationRadiographical examination:: Occipitomental viewsOccipitomental views Lateral skull viewsLateral skull views CT and 3D CTCT and 3D CT

3838

Management of nasal-orbital Management of nasal-orbital ethmoid fracturesethmoid fractures Examination for Examination for

determination of the extent determination of the extent of the injury (surgical of the injury (surgical exploration)exploration)

Nasal boneNasal bone Orbital and ethmoidalOrbital and ethmoidal Frontal boneFrontal bone

Debridement and closure of Debridement and closure of open woundsopen wounds

Reduction and stabilization Reduction and stabilization of bone fractureof bone fracture

3939

Detached canthusDetached canthusTraumatic telecanthusTraumatic telecanthus

Increase in inter-canthal distance Increase in inter-canthal distance secondary to secondary to

canthus displacement or detachmentcanthus displacement or detachment

Seen in association to:Seen in association to:Nasal boneNasal bone

NEONEO

Le Forts fracturesLe Forts fractures

4040

Surgical management of Surgical management of detached canthusdetached canthus Transnasal wiring Transnasal wiring

technique technique (unilateral (unilateral type)type)

Canthopexy Canthopexy Identification of the Identification of the

ligamentligament Liberation of the Liberation of the

periorbital tissueperiorbital tissue Liberation of the lacrimal Liberation of the lacrimal

pathwaypathway Nasal transfixationNasal transfixation Contralateral fixationContralateral fixation

4141

Lacrimal duct system injuryLacrimal duct system injury

The lacrimal sac can be torn by fragments The lacrimal sac can be torn by fragments of a comminuted fractureof a comminuted fracture

OrOr Compressed by a mass of callus Compressed by a mass of callus

which may block the nasolacrimal canalwhich may block the nasolacrimal canal

EPIPHORAEPIPHORA DacryocystitisDacryocystitis

4242

Reconstitution of the lacrimal passagesReconstitution of the lacrimal passages

Done at the same time of canthopexy viaDone at the same time of canthopexy via The original scarsThe original scars Lateral nasal incision (Lynch) Lateral nasal incision (Lynch) Bi-coronal incisionBi-coronal incision

Dacryocystorhinostomy Dacryocystorhinostomy If the sac remains intact, drainage of lacrimal fluid by probing If the sac remains intact, drainage of lacrimal fluid by probing

or removing of surrounded bone to allow drainage into the or removing of surrounded bone to allow drainage into the nosenose

Conjunctivo-rhinostomyConjunctivo-rhinostomyimplantation of a duct-like polythene tube or glass in case of implantation of a duct-like polythene tube or glass in case of

duct damageduct damage

Blow out fractures

Conventional radiography

CT of blow-out fractures of orbital floor

Blow-out and orbital emphysema

Blow-out through lamina papyracea

Uttalt pneumatisering av frontalsinus

Blow-out fracture upwards

Upward blow-out

Roof fracture

5252

Internal orbital fracturesInternal orbital fractures

In conjunction with other facial In conjunction with other facial fracturesfractures

As isolated type (Blow out As isolated type (Blow out fracture)fracture)

5353

AnatomyAnatomy

The floor is made of: The floor is made of: Maxillary bone and Maxillary bone and part of zygoma part of zygoma bounded laterally by bounded laterally by the inferior orbital the inferior orbital fissure and small part fissure and small part of the ethmoid boneof the ethmoid bone

5454

Clinical and radiographical Clinical and radiographical presentationpresentation

Subconjunctival ecchymosisSubconjunctival ecchymosis

Crepitation from air emphysemaCrepitation from air emphysema

Displacement of palpebral fissureDisplacement of palpebral fissure

Unequal pupillary levelsUnequal pupillary levels

DiplopiaDiplopia enophthalmosenophthalmos

5555

Diplopia and Diplopia and enophthalmousenophthalmous

Superior orbital fissure Superior orbital fissure syndromesyndrome

5656

TreatmentTreatment

Rational for intervention:Rational for intervention:

Small defect with no clinical consequence Small defect with no clinical consequence may not warrant the surgical intervention.may not warrant the surgical intervention.

Large defect with handicapping symptoms Large defect with handicapping symptoms should be operated.should be operated.

5757

Method of reconstructionMethod of reconstruction

Intra-sinus approach to Intra-sinus approach to the orbital floorthe orbital floor

External approach to External approach to the internal orbital floorthe internal orbital floor

5858

Materials in orbital Materials in orbital reconstructionreconstruction

Autologous graftAutologous graftBone (cranial, rib, iliac) Bone (cranial, rib, iliac) CartilageCartilage

Allogenic materialsAllogenic materialsLyophilized duraLyophilized dura

Alloplastic materialsAlloplastic materialsSiliastic and proplast Siliastic and proplast

implantsimplantsTeflonTeflonhydroxyapatitehydroxyapatiteTitanium mishTitanium mish

5959

Zygomatic complex fracturesZygomatic complex fractures

Zygomatic Arches: Anatomy

Prominent process called Zygomatic

processSquamous portion of

temporal bone:

Projects anteriorly

Articulates with zygoma

Anatomy of Zygomatic Articulations

1 )zygomatic Process

2 )Condyle of mandible

3 )Articular Tubercle

4 )Coronoid process

5 )Zygoma

Zygomatico-temporal Suture

6363

Zygomatic bone complexZygomatic bone complex

AnatomyAnatomyStar-shape like with four processesStar-shape like with four processes Frontal processFrontal process Temporal processTemporal process ButtressButtress Orbital floor (Maxilla and GWSB)Orbital floor (Maxilla and GWSB)

Temporal fascia and muscleTemporal fascia and muscle

Masseter muscleMasseter muscle

6464

Zygomatic complex and arch Zygomatic complex and arch fracturefracture

The malar bone represent a The malar bone represent a strong bone on fragile strong bone on fragile

supports, and it is for this supports, and it is for this reason that, though the reason that, though the

body of the bone is rarely body of the bone is rarely broken, the four broken, the four

processes- frontal, orbital, processes- frontal, orbital, maxillary and zygomatic maxillary and zygomatic

are frequent sites of are frequent sites of fracture.fracture.

Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.

6565

OccurrenceOccurrence

Observed in )>50%) of middle third fracture Observed in )>50%) of middle third fracture (in (in developed countries due to assaults)developed countries due to assaults)

The zygomatic arch fracture can be isolated The zygomatic arch fracture can be isolated in most of the casesin most of the cases

•As isolated fracture•In combination with other middle third fracture

•With internal orbital fracture )blow out)

Zygomatic Fractures

Isolated Zygomatic Arches

Isolated Zygomatic Arch Fractures

Tripod Fracture

Common Projections for Zygomatic Arches

SMV

Tangential: oblique inferosuperior

Modified Towne: AP Axial

SMV for Zygomatic Arches Seated or supine

IOML parallel with IR

MSP perpendicular

If supine: Flex knees Elevate trunk for full

neck extension Relax abdomen

CR perp to IOML and entering 1” posterior to outer canthi

SMV Radiographfor Zygomatic Arches

Zygomatic arches free from overlying structures

No rotation as indicated by symmetric arches w/o foreshortening

Mandibular symphysis SI frontal bone

SMV Radiograph and Diagrams

Tangential Projection forZygomatic arches

Seated or supine

IOML parallel with IR

MSP 15 degrees toward side being examined

Tilt vertex 15 degrees away from side being examined

CR perp to IOML and centered to arch at a point 1” posterior to outer canthus

Tangential Radiograph for Zygomatic arches

Zygomatic arch free from overlying structures

Zygomatic arch not overexposed

Collimate tightly

Tangential Anatomy

Tangential Obliques

Modified Towne: AP Axialfor Zygomatic Arches Seated or supine

MSP & OML perpendicular

CR to enter glabella approx 1” above nasion

OML: 30 caudad IOML 37 caudad

Modified Towne Radiograph for Zygomatic Arches

No overlap of zygomatic arches by mandible

No rotation as evident by symmetric arches

Arches projected lateral to mandibular rami

Modified Towne Anatomy

8282

Signs and symptomsSigns and symptoms

Periorbital ecchymosis and edemaPeriorbital ecchymosis and edema

Flattening of the malar prominenceFlattening of the malar prominence

Flattening over the zygomatic archFlattening over the zygomatic arch

Pain and tenderness on palpationPain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcusEcchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of the Deformity at the zygomatic buttress of the maxillamaxilla

Deformity at the orbital marginDeformity at the orbital margin

8383

TrismusTrismus Abnormal nerve sensibilityAbnormal nerve sensibility EpistaxisEpistaxis Subconjunctival ecchymosisSubconjunctival ecchymosis Crepitation from air emphysemaCrepitation from air emphysema Displacement of palpebral Displacement of palpebral

fissure fissure (pseudoptosis)(pseudoptosis) Unequal pupillary levelsUnequal pupillary levels DiplopiaDiplopia enophthalmosenophthalmos

8484

Clinical Clinical examinationexamination

InspectionInspection

PalpationPalpation

Visual examinationVisual examination Eye movementEye movement DiplopiaDiplopia Pupil reactionPupil reaction

8585

Radiographical evaluationRadiographical evaluation

Nothing is more valuable to the surgeon in Nothing is more valuable to the surgeon in determining the extent of injury and the position determining the extent of injury and the position

of the fragments-both before and after of the fragments-both before and after operation- than a good skiagram (radiograph)operation- than a good skiagram (radiograph)

8686

Occipitomental viewOccipitomental view

(Posterioanterior oblique)(Posterioanterior oblique)

(water’s view)(water’s view)

8787

submentovertexsubmentovertex

Recommended for isolated zygomatic arch fracture

8888

CT scanCT scan Coronal sectionsCoronal sections Axial sectionsAxial sections

8989

ClassificationsClassifications

DisplacementDisplacement

Rotation along the axis of FZ processesRotation along the axis of FZ processesAnterio-posterior displacementAnterio-posterior displacement

Rotation along the prominence of the boneRotation along the prominence of the boneMedio-lateral displacementMedio-lateral displacement

Extension of the fracture along processesExtension of the fracture along processes

points of fracturespoints of fractures

Combination with other injuriesCombination with other injuries

9090

TreatmentTreatment

Timing:Timing: As early as possible unless there are ophthalmic, cranial As early as possible unless there are ophthalmic, cranial

or medical complicationsor medical complications

Preiorbital edema and ecchymosis obscure the fine Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be postponed but details of the fracture, intervention can be postponed but not more than a weeknot more than a week

Indications:

•Diplopia•Restriction of mandibular movement

•Restoration of normal contour•Restoration of normal skeletal protection for the eye

9191

TreatmentTreatment

The methods of treating a fractured malar bone The methods of treating a fractured malar bone recommended by the various writers who have reported recommended by the various writers who have reported

cases include simple digital manipulation under genre real cases include simple digital manipulation under genre real anesthesia, external manipulation by means of a cow-horn anesthesia, external manipulation by means of a cow-horn dental forceps grasping the edges of the bone, traction and dental forceps grasping the edges of the bone, traction and elevation by means of wire or heavy bone elevators passed elevation by means of wire or heavy bone elevators passed

through small local external incisions, and elevation via through small local external incisions, and elevation via incision in the mucosa of the ginigival sulcus at the canine incision in the mucosa of the ginigival sulcus at the canine

fossa. Our technique, which has now been used fossa. Our technique, which has now been used successfully in a number of cases, differs from those successfully in a number of cases, differs from those

mentioned. mentioned.

9292

Methods of reductionMethods of reduction

Temporal approach (Gillies et al Temporal approach (Gillies et al 1927)1927)

Suitable for isolated zygomatic fracture with good stability afterwards

9393

Methods of reductionMethods of reduction

Percutaneous approach (malar hook, Percutaneous approach (malar hook, Carroll-Girard bone screw)Carroll-Girard bone screw)

Suitable for displaced zygomatic fracture with highStability after reduction

9494

Methods of reductionMethods of reduction

Buccal sulcus Buccal sulcus approach (Keen 1909)approach (Keen 1909)

Elevation from Elevation from eyebrow approacheyebrow approach

(the same principle of Gillies (the same principle of Gillies approach)approach)

9595

Open reduction and fixationOpen reduction and fixation

Transosseous wiring atTransosseous wiring at Frontozygomatic sutureFrontozygomatic suture Infraorbial rimInfraorbial rim

Surgery:

•Lateral eyebrow incision

•Infraorbital approach

9696

Open reduction and fixationOpen reduction and fixation

Rigid fixation using plate and screws atRigid fixation using plate and screws at Frontozygomatic sutureFrontozygomatic suture Infraorbial rimInfraorbial rim Inferior buttress of the zygomaInferior buttress of the zygoma

Surgery:

•Lateral eyebrow incision•Infraorbial approach•Subciliary (blepharoplasty) incision•Mid-lower lid incision•Transconjunctival approach

9797

Infraorbital rim and buttress

Lateral orbital rim

Buttress of zygoma

Points of fixation:

9898

Other methods of fixationOther methods of fixation

Kirschener wireKirschener wire

Pin fixationPin fixation

Antral packAntral pack

Zygomaticomaxillary fractures

Waters projection - Normal arch

Zygomatic fracture

Zygomatic arch fractures

Zygomatic arch fracture

3D- CT

3D-CT

Complications

Complication to zygomatic fracture

Closed mouth

Open mouth

1

2

Lé Fort fractures

LeFort Fracture 1

Le Fort I )“floating palate”) Characterized by a horizontal fracture through

the maxillary sinuses With separation of the entire palate and maxillary

alveolar processes. This fracture type includes the lower nasal

septum and inferior aspect of the pterygoid plates.

Le Fort Fracture 2 Le Fort II )“pyramidal”) is

characterized by an inverted ‘V’ type fracture through the medial orbital and lateral maxillary walls.

Through the nasal septum, frontal process of the maxilla, medial wall of the orbit, inferior orbital rim, superior, lateral, and posterior walls of the maxillary antrum, and midportion of the pterygoid plates.

This type of fracture can be associated with posterior displacement of the facial bones resulting in a “dish-face” deformity

Le Fort 3

Le Fort III )"craniofascial disjunction”) is Characterized by separation of the entire viscerocranium from

the base of the skull. Horizontal fracture through the orbits beginning near the

nasofrontal suture and extending posterior to involve the nasal septum, medial and lateral orbital walls, zygomatic arches, and base )superior aspect) of the pterygoid plates.

This type of fracture also may result in a “dish-face” deformity.

Lé Fort I

Lé Fort II

Le Fort 3 and mastication problem

Complications from upper midline fractures Mucocele Leakage of CSF Meningitis Lacrimal problem Telecantism Anosmia

Mucocele

Penetration from mucocele

Increased intercanthal distance

CSF-leakage after upper midline fracture

CSF leakage, Meningitis, Optic nerve damage

CSF leakage from temporal bone fracture

Air

Fluid

Lacrimal channel

Normal dacryocystography

Abnormal dacryocystography

Lacrimal problem

Name this fracture:

Le Fort 1

Name this fracture:

LEFORT 3

Name this fracture:

131131

Structures connectionStructures connection(structures in relation)(structures in relation)

OrbitOrbit Maxillary sinusMaxillary sinus Nasal boneNasal bone Naso-orbital ethmoid Naso-orbital ethmoid

(NOE) complex(NOE) complex Zygomatic complexZygomatic complex Frontal bone and sinusFrontal bone and sinus

132132

Le FortLe Fort’’s fracturess fracturesLe Fort I (low level or Le Fort I (low level or

Guerian fracture)Guerian fracture)Unilateral/ bilateralUnilateral/ bilateral

Horizontal fracture through Horizontal fracture through the maxilla above the the maxilla above the

level of the nasasl floor level of the nasasl floor and alveolar processand alveolar process

Piriform rimsPiriform rimsAnterior maxillaAnterior maxillaZygomatic buttressesZygomatic buttressesPtrygoid laminaePtrygoid laminae

133133

Signs and symptomsSigns and symptoms Slight swelling of upper lipSlight swelling of upper lip

Ecchymosis in upper lip sulcusEcchymosis in upper lip sulcus

Hematoma intra-orally over zygoma and in palateHematoma intra-orally over zygoma and in palate

Disturbed occlusionDisturbed occlusion

Mobility of teeth of the involved segment of maxillaMobility of teeth of the involved segment of maxilla

Combination of soft tissue lacerationCombination of soft tissue laceration

Exposure of nares and the maxillary antra in case of gross injuryExposure of nares and the maxillary antra in case of gross injury

Impacted type of fracture is oftenly not mobile and teeth cusps Impacted type of fracture is oftenly not mobile and teeth cusps may be damagedmay be damaged

Cracked-pot percussion of upper teethCracked-pot percussion of upper teeth

134134

Le FortLe Fort’’s fracturess fractures

Le Fort IILe Fort II (pyramidal or subzygomatic)(pyramidal or subzygomatic)

Separation of NF suture, medial Separation of NF suture, medial orbital walls (lacrimal bone), orbital walls (lacrimal bone), inferior orbital floor and rim inferior orbital floor and rim (adjacent to infrorbital canal (adjacent to infrorbital canal and foramen), anterior maxilla and foramen), anterior maxilla below zygomatic buttress and below zygomatic buttress and ptrygoid laminae about halfway ptrygoid laminae about halfway up.up.

Separation of the block from the base of skull is completed Separation of the block from the base of skull is completed via the nasal septum and may involve the floor of the via the nasal septum and may involve the floor of the anterior cranial fossaanterior cranial fossa

135135

LeFortLeFort’’s fracturess fractures

LeFort III LeFort III (cranifacial dysjunction, high transverse, (cranifacial dysjunction, high transverse,

suprazygomatic)suprazygomatic)

Separation of NF suture, medial Separation of NF suture, medial orbital walls (involve the depth of the orbital walls (involve the depth of the

ethmoid bone and cribriform plate, ethmoid bone and cribriform plate, pass below optic foramen and cross pass below optic foramen and cross

the inferior orbital fissur), inferior the inferior orbital fissur), inferior orbital floor, lateral orbital wall, ZF orbital floor, lateral orbital wall, ZF

suture, zygomatic arch, suture, zygomatic arch, suprazygomatic to the root of suprazygomatic to the root of

ptrygoid plate.ptrygoid plate.

136136

Signs and symptomsSigns and symptomsalthough it is possible to distinguish between le fort II and although it is possible to distinguish between le fort II and III, the signs and symptoms are almost similarIII, the signs and symptoms are almost similar

Gross edema of soft tissueGross edema of soft tissue Bilateral circumorbital Bilateral circumorbital

ecchymosisecchymosis Bilateral subconjunctival Bilateral subconjunctival

hemorrahgehemorrahge Obvious deformity of the noseObvious deformity of the nose Nasal bleeding and obstructionNasal bleeding and obstruction CSF leak rhinorrheaCSF leak rhinorrhea Dish-face deformityDish-face deformity Limitation of ocular movementLimitation of ocular movement Possible diplopia and Possible diplopia and

enophthalmousenophthalmous Retropostioning of the maxilla Retropostioning of the maxilla

with anterior open bitewith anterior open bite Lengthening of the faceLengthening of the face

Difficulty in mouth openingDifficulty in mouth opening Mobility of the upper jawMobility of the upper jaw Occusional hematoma of the Occusional hematoma of the

palatepalate Cracked-pot sound on Cracked-pot sound on

percussionpercussion Step deformity at infra-orbiatal Step deformity at infra-orbiatal

marginmargin Anasthesia of midfaceAnasthesia of midface Nasal bone moves with mid-face Nasal bone moves with mid-face

as a wholeas a whole Tenderness and sepration at FZ Tenderness and sepration at FZ

suturesuture Tenderness and deformity of Tenderness and deformity of

zygomatic archzygomatic arch Depression of occular level and Depression of occular level and

pseudoptosispseudoptosis

137137

Bowerman classification of midface-fracture Bowerman classification of midface-fracture (1994)(1994)

Fracture not involving the occlusionFracture not involving the occlusion Central regionCentral region

Nasal bone/ septum (lateral, anterior injuries)Nasal bone/ septum (lateral, anterior injuries) Frontal process of the maxillaFrontal process of the maxilla NasoethmoidNasoethmoid Fronto-orbito-nasal dislocationFronto-orbito-nasal dislocation

Lateral region (zygomatic complex EX dento alveolar frcatureLateral region (zygomatic complex EX dento alveolar frcature

Fracture involving the occlusionFracture involving the occlusion Dento alveolarDento alveolar

Subzygomatic:Subzygomatic: Le Fort’s (I, II)Le Fort’s (I, II)

Supra zygomatic: Supra zygomatic: Le Fort IIILe Fort III

These fractures may occur unilaterally or bilaterally, with separation of maxillary midline and or extension to frontal or temporal bone

138138

Prevalence of mid-face fracturesPrevalence of mid-face fractures

Fracture TypeFracture Type PrevalencePrevalence

Zygomaticomaxillary complex (tripod fracture)Zygomaticomaxillary complex (tripod fracture) 40 %40 %

LeFortLeFort

II 15 %15 %

IIII 10 %10 %

IIIIII 10 %10 %

Zygomatic archZygomatic arch 10 %10 %

Alveolar process of maxillaAlveolar process of maxilla 5 %5 %

Smash fracturesSmash fractures 5 %5 %

OtherOther 5 %5 %

139139

DiagnosisDiagnosis

InspectionInspection Extra-oral Extra-oral )e.g. swelling, deformity, asymmetry)e.g. swelling, deformity, asymmetryLeaks) Leaks)

Intra-oralIntra-oral)e.g. hematoma, occlusion))e.g. hematoma, occlusion)

PalpationPalpationStep deformity, criptation, cracked pot sound, mobilityStep deformity, criptation, cracked pot sound, mobility

Radiographical investigationsRadiographical investigations

140140

Radiographical examinationRadiographical examinationPlain radiographPlain radiograph

OccipitomentalOccipitomental

)10 or 30 degree))10 or 30 degree) Water’s viewWater’s viewSuitable for isolated orbital fractureSuitable for isolated orbital fracture

Search line (Campbell’s line 1977)

141141

Radiographical examinationRadiographical examination

Lateral skull viewLateral skull view OPGOPG Occlusal view of the maxillaOcclusal view of the maxilla Perapical views of damaged Perapical views of damaged

teethteeth

142142

Radiographical examinationRadiographical examination

CT scanCT scan 3-D CT imaging3-D CT imaging

Coronal sectionsCoronal sections Axial sectionsAxial sections

1. Whenever intracranial damage and frontal sinus are suspected

2. Extensive fracture that involves nasoethmoid complex or orbital region

3. Orbital trauma to evaluate the degree of orbital injury and enophthalmos

143143

144144

Indications for treatmentIndications for treatment

Physical signs of a fracture of the maxilla.Physical signs of a fracture of the maxilla.

Evidence of a fractured maxilla on imaging.Evidence of a fractured maxilla on imaging.

Disruption of the occlusion of the teeth.Disruption of the occlusion of the teeth.

Displacement of the maxilla.Displacement of the maxilla.

Post traumatic facial deformity.Post traumatic facial deformity.

145145

Indications for treatmentIndications for treatment

Fractured or displaced teeth.Fractured or displaced teeth.

Cerebrospinal fluid leak.Cerebrospinal fluid leak.

Abnormal eye movement or restriction of eye movement.Abnormal eye movement or restriction of eye movement.

Occlusion of the nasolacrimal duct.Occlusion of the nasolacrimal duct.

Sensory or motor nerve deficit.Sensory or motor nerve deficit.

Other evidence of loss of functionOther evidence of loss of function

146146

Aims of treatmentAims of treatment Relieve painRelieve pain

Restore function.Restore function.

Restore bone anatomy.Restore bone anatomy.

Prevent infectionPrevent infection

Restore the dental occlusionRestore the dental occlusion

Restore jaw movement at the earliest possible stageRestore jaw movement at the earliest possible stage

Restore normal nerve functionRestore normal nerve function

147147

Factors affecting the riskFactors affecting the risk

Association with multiple injuries.Association with multiple injuries.

Presence of uncontrolled haemorrhagePresence of uncontrolled haemorrhage

Impairment of the airway.Impairment of the airway.

Presence of bone comminutionPresence of bone comminution

Association with a dural tear.Association with a dural tear.

Association with a base of skull fracture.Association with a base of skull fracture.

148148

Factors affecting the riskFactors affecting the risk

Presence of a pre-existing dentofacial deformity.Presence of a pre-existing dentofacial deformity.

Time elapsed since the injury.Time elapsed since the injury.

Presence of a medical or surgical factor which would delay Presence of a medical or surgical factor which would delay general anesthesiageneral anesthesia

Presence of any factor which would delay healing. (eg Presence of any factor which would delay healing. (eg nutritional deficiency or alcoholism)nutritional deficiency or alcoholism)

Stage of dental development (deciduous, mixed or Stage of dental development (deciduous, mixed or permanent dentition)permanent dentition)

149149

Factors affecting the riskFactors affecting the risk

Presence of fractured teeth.Presence of fractured teeth.

Total absence of teeth (edentulous)Total absence of teeth (edentulous)

Inability of the patient to co-operate with treatment.Inability of the patient to co-operate with treatment.

Association with fractures of the mandible especially Association with fractures of the mandible especially bilateral fractures of the condyles.bilateral fractures of the condyles.

150150

Principles of treatmentPrinciples of treatment

Closed reduction may be appropriate in casesClosed reduction may be appropriate in cases

Simple uncomplicated fracturesSimple uncomplicated fractures

Complex or comminuted fracturesComplex or comminuted fractures

Medical or surgical contraindications to open Medical or surgical contraindications to open reductionreduction

Maxillary fractures in childrenMaxillary fractures in children

151151

Open reduction may be appropriate whereOpen reduction may be appropriate where

Immediate or early jaw function is desirableImmediate or early jaw function is desirable

Difficulty is encountered in reducing the Difficulty is encountered in reducing the

fracture by a closed methodfracture by a closed method

The fracture is unstableThe fracture is unstable

152152

Definitive treatmentDefinitive treatment

ReductionReduction

Manual manipulationManual manipulation

Use of dis-impaction forcepsUse of dis-impaction forceps

153153

Fixation and immobilizationFixation and immobilization

Extraoral fixationExtraoral fixation

Craniomandibular fixationCraniomandibular fixationBox-frame (pin fixation)Box-frame (pin fixation)

Halo-frameHalo-frame

Plaster of paries headcapPlaster of paries headcap

Craniomaxillary fixationCraniomaxillary fixationSupra-orbital pinsSupra-orbital pins

Zygomatic pinsZygomatic pins

Halo-frameHalo-frame

154154

Immobilization within the tissueImmobilization within the tissueDirect fixationDirect fixation

Transosseous wiring at Transosseous wiring at

fracture sitesfracture sites Frontozygomatic suturesFrontozygomatic sutures Infrorbital marginInfrorbital margin Midline of the palateMidline of the palate

155155

Immobilization within the tissueImmobilization within the tissue

Internal-wire suspensionInternal-wire suspension

Circumzygomatico-mandibularCircumzygomatico-mandibular

Infraorbital border-mandibularInfraorbital border-mandibular

FrontomandibularFrontomandibular

Pyriform fossa-mandibularPyriform fossa-mandibular

156156

Immobilization within the tissueImmobilization within the tissue

Support via the maxillary sinus by filling Support via the maxillary sinus by filling materialsmaterials

Ribbon gauzeRibbon gauze BalloonBalloon Folly catheterFolly catheter Polyethylene materialPolyethylene material

157157

Length of the hospital stay will depend on a Length of the hospital stay will depend on a number of factors including:number of factors including:

Presence of other injuriesPresence of other injuries

Age and medical status of the patientAge and medical status of the patient

Severity of the injurySeverity of the injury

Technique employed in the reduction and fixation of Technique employed in the reduction and fixation of the fracturethe fracture

Presence or absence of medical or surgical Presence or absence of medical or surgical complicationscomplications

Social circumstances of the patient Social circumstances of the patient

158158

Maxillofacial TraumaMaxillofacial Trauma

Mandibular FracturesMandibular Fractures

Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages

with two nutrient arteries

159159

Mandible in traumaMandible in trauma Mandibular fracture is more common than middle third Mandibular fracture is more common than middle third

fracture fracture (anatomical factor)(anatomical factor)

It could be observed either alone or in combination with It could be observed either alone or in combination with other facial fracturesother facial fractures

Minor mandibular fracture may be associated with head Minor mandibular fracture may be associated with head injury owing to the cranio-mandibular articulationinjury owing to the cranio-mandibular articulation

Mandibular fracture may compromise the patency of the Mandibular fracture may compromise the patency of the airway in particular with loss of consciousnessairway in particular with loss of consciousness

Fracture of mandible occurred with frontal impact force as Fracture of mandible occurred with frontal impact force as low as 425 lb (190 Kg) low as 425 lb (190 Kg) {Condylar fracture}{Condylar fracture}

160160

Fracture of condyle regarded as a safety mechanism to the Fracture of condyle regarded as a safety mechanism to the patientpatient

Frontal force of 800-900 lb (350-400 Kg) is required to cause Frontal force of 800-900 lb (350-400 Kg) is required to cause symphesial fracturesymphesial fracture

Mandible was more sensitive to lateral impact than frontal Mandible was more sensitive to lateral impact than frontal oneone

Frontal impact is substantially cushioned by opening and Frontal impact is substantially cushioned by opening and retrusion of the jawretrusion of the jaw

(Nahum 1975(Nahum 1975))

Long canine tooth and partially erupted wisdoms represent Long canine tooth and partially erupted wisdoms represent line of relatively weaknessline of relatively weakness

161161

Anatomical considerationsAnatomical considerations

Attached muscles:Attached muscles: MasseterMasseter TemporalisTemporalis Medial and lateral Medial and lateral

pterygoidpterygoid MylohyoidMylohyoid Geniohyoid and Geniohyoid and

genioglosusgenioglosus anterior belly of anterior belly of

digastricsdigastrics

162162

Blood supplyBlood supply Endosteal supply via the ID artery and veinEndosteal supply via the ID artery and vein Periosteal supply, important in aging due to Periosteal supply, important in aging due to

diminishes and disappearance of alveolar arterydiminishes and disappearance of alveolar artery

Nerve Nerve Damage of inferior dental nerveDamage of inferior dental nerve Facial palsy by direct trauma to ramusFacial palsy by direct trauma to ramus Damage of facial nerve in temporal bone fractureDamage of facial nerve in temporal bone fracture

Damage to mandibular division of facial nerveDamage to mandibular division of facial nerve

163163

Factors influenced site of Factors influenced site of fracture and displacementfracture and displacement Anatomy of the mandible Anatomy of the mandible

and attached muscle and attached muscle (canine & wisdoms)(canine & wisdoms)

Weakening areas of Weakening areas of mandible (resorption and mandible (resorption and pathologyl)pathologyl)

Direction of force of the Direction of force of the blowblow

Age of the patientAge of the patient

164164

Types of fractureTypes of fracture SimpleSimple

Greenstick fracture (rare, exclusively in children)Greenstick fracture (rare, exclusively in children) Fracture with no displacement (Linear)Fracture with no displacement (Linear) Fracture with minimal displacementFracture with minimal displacement

Displaced fractureDisplaced fracture

Comminuted fractureComminuted fractureExtensive breakage with possible bone and soft tissue lossExtensive breakage with possible bone and soft tissue loss Compound fractureCompound fractureSevere and tooth bearing area fracturesSevere and tooth bearing area fractures Pathological fracturePathological fracture(osteomyelities, neoplasm and generalized skeletal disease)(osteomyelities, neoplasm and generalized skeletal disease)

165165

Sites of fracturesSites of fractures Condyle fractureCondyle fracture

Intracapsular fractureIntracapsular fracture Extracapsular fractureExtracapsular fracture

High condyle neck fractureHigh condyle neck fracture Low condylar fractureLow condylar fracture

Angle/ ramus fractureAngle/ ramus fracture )body )body fracture)fracture)

Canine regionCanine region )parasymphesial )parasymphesial fracture)fracture)

Midline fractureMidline fracture )symphesis )symphesis fracture)fracture)

Coronoid fractureCoronoid fracture )rare) )rare)

166166

Incidence of mandibular Incidence of mandibular fracturesfractures Body fractures 33.6%Body fractures 33.6%

Subcondylar fracture 33.4%Subcondylar fracture 33.4%

Fractures at the angle 17.4%Fractures at the angle 17.4%

Alveolar fractures 6.7%Alveolar fractures 6.7%

Ramus fractures 5.4%Ramus fractures 5.4%

Midline fractures 2.9%Midline fractures 2.9%

Fracture of coronoid process 1.3%Fracture of coronoid process 1.3%Oikarinen & Malmstrom 1969Oikarinen & Malmstrom 1969

167167

Favourable or Favourable or unfavourableunfavourable They can be vertically or horizontally in directionThey can be vertically or horizontally in direction

They are influenced by the medial pterygoid-They are influenced by the medial pterygoid-masseter “sling”masseter “sling”

If the vertical direction of the fracture favours the If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled linguallyposterior fragment will be pulled lingually

If the horizontal direction of the fracture favours the If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled upward direction, the posterior fragment will be pulled linguallylingually

Favourable fracture line makes the reduced Favourable fracture line makes the reduced fragment easier to stabilizefragment easier to stabilize

168168

Effects of muscles on Effects of muscles on displacementdisplacement Transverse midline fracture )symphesial) stabilizes Transverse midline fracture )symphesial) stabilizes

by the action of mylohyoid and geniohyoidby the action of mylohyoid and geniohyoid

Oblique fracture )parasymphesial) tends to overlap Oblique fracture )parasymphesial) tends to overlap under the influence of muscles actionunder the influence of muscles action

Bilateral parasymphesial fracture results in Bilateral parasymphesial fracture results in backward displacement associated with loss of backward displacement associated with loss of tongue control when the level of consciousness is tongue control when the level of consciousness is depresseddepressed

169169

Condylar fracturesCondylar fracturesThe most common mandibular fracture The most common mandibular fracture

Unilateral or bilateralUnilateral or bilateral Intracapsular or extracapsularIntracapsular or extracapsular

Antero-medial displacement is common Antero-medial displacement is common but it may remain but it may remain

angulated with the ramusangulated with the ramus

Dislocation of the glenoid fossa and Dislocation of the glenoid fossa and fracture of petrous temporal bone which fracture of petrous temporal bone which is very rareis very rare

170170

Sign and symptomsSign and symptoms

Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness and restriction of movement

Deviation of mandible towards the side of fractureDeviation of mandible towards the side of fracture

Gagging of occlussion (premature contact on the posterior teeth) Gagging of occlussion (premature contact on the posterior teeth) with bilateral condylar displaced or over-riding fractureswith bilateral condylar displaced or over-riding fractures

Displacement of mandible toward the affected sideDisplacement of mandible toward the affected side

Anterior open bite on opposite side of fractureAnterior open bite on opposite side of fracture

Laceration of EAM****Laceration of EAM****

Retroauricular ecchymosis****Retroauricular ecchymosis****

Cerebrospinal leak and otorrhea in association with skull base Cerebrospinal leak and otorrhea in association with skull base fracturefracture

Condylar fracturesCondylar fractures

171171

Sequlae of TMJ injurySequlae of TMJ injury Artheritic changesArtheritic changes

Haemartherosis, fibrosis and aknylosisHaemartherosis, fibrosis and aknylosis

Meniscal damage and detachmentMeniscal damage and detachment

TMDTMD

Staph infectionStaph infection with condylar backward displacement and with condylar backward displacement and external auditory meatus injuryexternal auditory meatus injury

MeningitisMeningitis with petrous temporal bone fracture and with petrous temporal bone fracture and intracranial involvementintracranial involvement

Condylar fracturesCondylar fractures

172172

Coronoid process fracture:Coronoid process fracture:

Rare fracture caused by direct trauma to ramus Rare fracture caused by direct trauma to ramus and results from reflux contraction of temporalisand results from reflux contraction of temporalis

Can be seen following operation of large ramus Can be seen following operation of large ramus cystcyst

Elicit tenderness over the anterior part of ramusElicit tenderness over the anterior part of ramus

Development of tell-tale haematomaDevelopment of tell-tale haematoma

173173

Fracture of the ramus:Fracture of the ramus: Type I Single fractureType I Single fracture

Mimics low condylar fracture that runs below Mimics low condylar fracture that runs below the sigmoid notchthe sigmoid notch

Type II comminuted fractureType II comminuted fracture

Common in missile injuries and appears to be Common in missile injuries and appears to be with little displacement due to effects of with little displacement due to effects of messeter and medial pterygoid musclesmesseter and medial pterygoid muscles

174174

Fracture of the angle and bodyFracture of the angle and body Pain, tenderness and trismusPain, tenderness and trismus

Extra-oral swelling at the angle with obvious Extra-oral swelling at the angle with obvious deformitydeformity

Step deformity behind the molar teethStep deformity behind the molar teeth

Movement and crepitus at the fracture siteMovement and crepitus at the fracture site

Derangement of occlussionDerangement of occlussion

Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma

Involvement of IDNInvolvement of IDN

Gingival tear if fracture in dentated areaGingival tear if fracture in dentated area

Tooth involvement and possible longitudinal Tooth involvement and possible longitudinal split fracturesplit fracture

175175

Midline fractureMidline fracture The most common missed fracture (always The most common missed fracture (always

fine crack)fine crack)

Can be symphesial or parasymphesial Can be symphesial or parasymphesial fracturefracture

Commonly associated with one or both Commonly associated with one or both condyles fracturecondyles fracture

Unilateral fracture leads to over-riding of Unilateral fracture leads to over-riding of the fragments and bilateral may contribute the fragments and bilateral may contribute in loss of voluntery tongue controlin loss of voluntery tongue control

Long canine tooth represent a weak area Long canine tooth represent a weak area and contributes to parasymphesial fracture and contributes to parasymphesial fracture

Rarely runs across mental foramenRarely runs across mental foramen

176176

Signs and symptomsSigns and symptoms Pain and tendernessPain and tenderness Swelling and odemeaSwelling and odemea Development of step deformityDevelopment of step deformity Mental anesthesiaMental anesthesia Heamatoma in the floor of mouth and buccal mucosa Heamatoma in the floor of mouth and buccal mucosa Soft tissue injury of the chin and lower lipSoft tissue injury of the chin and lower lip

If associated with condylar fracturesIf associated with condylar fractures

Absence of condyle movement on the contrlateral sideAbsence of condyle movement on the contrlateral side Deviation of mandibleDeviation of mandible Anterior open biteAnterior open bite Gagging of oclussionGagging of oclussion Limitation of mouth openingLimitation of mouth opening

Midline fracture

177177

Clinical assessment and Clinical assessment and diagnosisdiagnosis

History of traumaHistory of trauma (traumatized patients with possible head injury) and facial injuries(traumatized patients with possible head injury) and facial injuries

Clinical ExaminationClinical Examination▶▶ ExtroralExtroral

Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds)wounds)

Palpation for eliction of tenderness, pain, step deformity and malfunctionPalpation for eliction of tenderness, pain, step deformity and malfunction

▶▶ Intra- and paraoralIntra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussion and bleeding, heamatoma, gingival tear, gagging of occlussion and

step deformity and sensory and motor deficiencystep deformity and sensory and motor deficiency

RadiographsRadiographs

178178

RadiographsRadiographs

Plain radiographPlain radiograph OPGOPG Lateral obliqueLateral oblique PA mandiblePA mandible AP mandible )reverse AP mandible )reverse

Townes)Townes) Lower occlusalLower occlusal

CT scanCT scan 3-D CT imaging3-D CT imaging MRIMRI

179179

Principles of treatmentPrinciples of treatmentsimilar to elsewhere fractures in the bodysimilar to elsewhere fractures in the body

Reduction of fragments in good positionReduction of fragments in good position

Immobilization until bony union occursImmobilization until bony union occurs

These are achieved by:These are achieved by: Close reduction and immobilizationClose reduction and immobilization Open reduction and rigid fixationOpen reduction and rigid fixation

Other objective of mandible fracture treatment:Other objective of mandible fracture treatment: Control of bleedingControl of bleeding

Control of infectionControl of infection

180180

Definitive treatmentDefinitive treatment Soft tissue repairSoft tissue repair DebridmentDebridment Irrigation with saline and antibioticsIrrigation with saline and antibiotics Closure in layersClosure in layers Dressing Dressing

Reduction and fixation of the jawReduction and fixation of the jaw▶▶ Close reduction and IMF (traditional method by means of Close reduction and IMF (traditional method by means of

manipulation)manipulation)▶▶ Open reduction and semi-rigid fixation (using inter-ossous Open reduction and semi-rigid fixation (using inter-ossous

wirings)wirings)▶▶ Open reduction and rigid fixation (using bone palates Open reduction and rigid fixation (using bone palates

osteosynthesis)osteosynthesis)

Objective:Objective: Restoration of functional alignment of the bone fragments in Restoration of functional alignment of the bone fragments in

anatomically precise position utilizing the present teeth for anatomically precise position utilizing the present teeth for guidanceguidance

181181

Close reductionClose reduction

Arch barsArch bars JelenkoJelenko Erich patternErich pattern German silver notchedGerman silver notched

Cap splintsCap splints

▶▶ IMF prior to rigid fixationIMF prior to rigid fixation

▶▶ For the purpose of close For the purpose of close reductionreduction

182182

Close reductionClose reduction

Bonded bracketsBonded brackets

IMF screwsIMF screws

Dental wiring:Dental wiring: Direct wiringDirect wiring Eyelet wiringEyelet wiring Local anesthesia orLocal anesthesia or

sedationsedation

Minimal displacementMinimal displacement IMF for 6 weeksIMF for 6 weeks Treatment can be performed Treatment can be performed

under GA or LA and when under GA or LA and when surgery is contraindicatedsurgery is contraindicated

183183

Fracture mandible in Fracture mandible in childrenchildren Close reductionClose reduction Open reduction and Open reduction and

fixationfixation Plating at the inferior Plating at the inferior

borderborder Resorpable platesResorpable plates

184184

GunningGunning’’s splints splint

Old modalityOld modality Edentulous patientEdentulous patient Rigid fixation is not Rigid fixation is not

possiblepossible To establish the To establish the

occlusionocclusion

185185

Open reduction and fixationOpen reduction and fixation

Intraoral approachIntraoral approach

Extraoral approachExtraoral approach

▶▶ Submandibular Submandibular approachapproach

186186

Rigid fixationRigid fixation

Intraossous wiringIntraossous wiring Plates and screwsPlates and screws Kirchener wireKirchener wire Lag screwsLag screws

187187

Reconstruction palateReconstruction palate

Severe trauma

Loss of part of the bone

188188

Condylar fracturesCondylar fractures

Intraoral approachIntraoral approach

Ramus incisionRamus incision

Extraoral approachExtraoral approachPreauricular approachPreauricular approach

Retromandibular approachRetromandibular approach

189189

IMFIMF

Transosseous wiringTransosseous wiring

Circumferential wiringCircumferential wiring

External pin fixationExternal pin fixation

Bone clampsBone clamps

Trans-fixation with Kirschner wiresTrans-fixation with Kirschner wires

190190

OsteosynthesisOsteosynthesis

Non-compression small platesNon-compression small plates

Compression platesCompression plates

MiniplatesMiniplates

Lag screwsLag screws

Resorbable plates and screwsResorbable plates and screws

191191

Teeth in the fracture lineTeeth in the fracture line

The fracture is compound into the mouthThe fracture is compound into the mouth

The tooth may be damaged or lose its blood The tooth may be damaged or lose its blood supplysupply

The tooth may be affected by some The tooth may be affected by some preexisting pathologypreexisting pathology

192192

Management of teeth retained in fracture Management of teeth retained in fracture lineline

Good quality intra-oral periapical radiographGood quality intra-oral periapical radiograph Insinuation of appropriate systemic antibiotic Insinuation of appropriate systemic antibiotic

therapytherapy Splinting of tooth if mobileSplinting of tooth if mobile Endodontic therapy if pulp is exposedEndodontic therapy if pulp is exposed Immediate extraction if fracture becomes infectedImmediate extraction if fracture becomes infected Follow up for 1 year and endodontic therapy if there Follow up for 1 year and endodontic therapy if there

is a loss of vitalityis a loss of vitality

193193

Absolute indicationsAbsolute indications Longitudinal fractureLongitudinal fracture Dislocation or subluxation from socketDislocation or subluxation from socket Presence of periapical infectionPresence of periapical infection Infected fracture lineInfected fracture line Acute pericoronitisAcute pericoronitis

Relative indicationsRelative indications Functional tooth that would be removedFunctional tooth that would be removed Advanced caries or periodontal diseases Advanced caries or periodontal diseases Doubtful tooth which would be added to existing dentureDoubtful tooth which would be added to existing denture Tooth in untreated fracture presenting more than 3 days Tooth in untreated fracture presenting more than 3 days

after injuryafter injury

Fracture of temporal bone

Classifications

1. Longitudinal fractures

2. Transverse fractures

3. Mixed fractures

Longitudinal fractures

80% of Temporal Bone Fractures

Lateral Forces along the petrosquamous suture line

15-20% Facial Nerve involvement

EAC laceration

Transverse fractures

20% of Temporal Bone Fractures

Forces in the Antero-Posterior direction

Inner ear injury 50% Facial Nerve

Involvement EAC intact

Physical Examination

Tuning Fork exam Pneumatic Otoscopy

Imaging

HRCT MRI Angiography/ MRA

symptoms

Hearing Loss & tinnitus Dizziness CSF Otorrhea and

Rhinorrhea Facial Nerve Injuries

Hearing loss

Formal Audiometry vs. Tuning Fork 71% of patients with Temporal Bone Trauma

have hearing loss TM Perforations

CHL > 40db suspicion for ossicular discontinuity

Hearing loss

Longitudinal Fractures Conductive or mixed hearing

loss 80% of CHL resolve

spontaneously Transverse Fractures

Sensorineural hearing loss Less likely to improve

Dizziness

Otic capsule fracture, labyrinthine concussion, Perilymphatic Fistula

Perilymphatic Fistulas Fluctuating dizziness and/or hearing loss Tulio’s Phenomenon Management

40% spontaneously close Surgical management

Dizziness

BPPV Acute, latent, and

fatigable vertigo Can occur any time

following injury Dix Hallpike Epley Maneuver

CSF Otorrhea and Rhinorrhea Temporal bone Fractures are the most

common cause of CSF Otorrhea Beta-2-transferrin HRCT

CSF Otorrhea and Rhinorrhea Management

Conservative therapy Lie in bed with Head elevated 30-45°

Antibiotics Surgery

CSF Otorrhea and RhinorrheaSurgical Management Surgical approach

Status of hearing Meningocele/encephalocele Fistula location

Transmastoid Middle Cranial Fossa

Facial Nerve Injuries

Evaluation Previous status Time Onset and progression Complete vs. Incomplete

House Brackman grading systemI Normal Normal facial functionII Mild Slight synkinesis/weaknessIIIModerate Complete eye closure, noticeable

synkinesis, slight forehead movementIVModerately Severe Incomplete eye closure,

symmetry at rest, no forehead movementV Severe Assymetry at rest, barely noticeable

motionVITotal No movement

Electrophysiologic Testing

NET MST ENoG

Nerve Excitability TestMaximal Stimulation Test >3.5mA difference suggests a poor prognosis

for return of facial function

Electroneuronography

Most accurate, qualitative measurement Reduction of >90% amplitude correlates with

a poor prognosis for spontaneous recovery

Electromyography

Limited use until 10-14 days Polyphasic potentials= Good

Facial Nerve Injuries

Decision to treat is primarily based on whether there is complete vs. incomplete paralysis

Treatment

Conservative treatment candidates Surgical candidates

Conservative Treatment Candidates Chang and Cass

Normal Facial Function regardless of progression Incomplete paralysis and no progression to

complete paralysis Less than 95% degeneration by ENoG

Surgical Candidates

Critical Prognostic factors Immediate vs. Delayed Complete vs. Incomplete paralysis ENoG criteria

Algorithm for Facial Nerve Injury

Surgical Approach

Suspect location of neural injury Presence or absence of hearing

Surgical Approach

Lateral to the geniculate ganglion transmastoid

Medial to the Geniculate Ganglion No useful hearing

Transmastoid-translabyrinthine Intact hearing

Transmastoid-trans-epitympanic Middle Cranial Fossa

Surgical findings

Nerve repair Direct anastomosis Nerve graft

Decompression

Case Report

32 yr old fisherman was wading Minding his own business

Hit in head by a flying fish Immediate profound vertigo, hearing loss CT scan revealed longitudinal Temp bone

fracture

Types of Weapons

Low velocity – knives, ice picks, glass High velocity – handguns, shotguns, shrapnel

Guns

Ballistics

Ballistics

Management of Penetrating Neck Trauma

Ballistics

Anatomy

Anatomy

Incision for Neck Exploration:

Incisions for Neck Exploration:

Incidence and Mortality

Initial Management

Signs of Injury:

Signs of Injury:

Management of the Stable Patient:

The Old Standard:

The Old Standard:

Based on wartime experiences Fogelman et al )1956) showed that

immediate neck exploration led to better outcomes in study group for vascular injuries.

Led to rate of negative neck explorations in > 50%

Arteriogram slowly began to gain acceptance as screening tool before exploration, especially for zone 1 and 3 injuries )hard to detect on physical).

Cervical Spine Stenosis

Mechanism/Etiology Narrowing of spinal canal

Assessment Diagnostic Tests

X-rays MRI CAT scan

Treatment Non-surgical Surgical

Cervical Fractures

Types of Fractures Atlanto-axial

Mechanism Hyperextension Children >adults

Cervical Fractures

Types of Fractures Atlanto-axial Jefferson

Mechanism Compressive Force Burst Fracture

Anterior arch

Posterior archAnterior arch

Cervical Fractures

Types of Fractures Atlanto-axial Jefferson Hangman’s fracture

Mechanism Hyperextension/

compression force Fracture to C2 Pedicle C2 with anterior

slippage of C2/C3

Cervical Fractures

Types of Fractures Atlanto-axial Jefferson Hangman’s fracture Burst

AKA Compression Fx Mechanism

Flexion Vertebral body Neurology

Cervical Fractures

Types of Fractures Atlanto-axial Jefferson Hangman’s fracture Burst Clay-Shovelers

Spinous process of C6 or C7

Mechanism Result of rotations of

trunk relative to neck

Cervical Fractures

Types of Fractures Atlanto-axial Jefferson Hangman’s fracture Burst Clay-Shovelers Tear Drop

Violent extension force

Cervical Fractures

Assessment History/Mechanism Inspection Palpation Functional Test Neurological Exam

Questions and Answers