Management of maxillofacial

injuries

Instructor – Dr. Jesus George

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Introduction

The facial skeleton is divided into 3 parts

Upper 1/3-formed by frontal boneMiddle 1/3-from frontal bone to the level of

upper teethLower 1/3-the mandible

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The causes of maxillofacial injuries

FightsFallsRoad traffic accidentsOccupational hazards-athletic injury,

industrial mishapsIatrogenic causes-# of tooth,

alveolus,maxillary tuberosity,# of mandible during dental treatment.

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Examination of patient with maxillofacial trauma

History of injuryObtained from the patient or relatives or the

witness of injury.Who-name,age,sex,address,phone numberWhen-date & time of injury.Where-the surroundings of injury.How-type of violence & direction of force.

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Cont.

What-type of treatment given before the patient comes here.

What- is the general health of the patient.h/o allergy,bleeding disorders,any systemic bone disease,neoplasm,arthritis

Previous h/o traumaLength of unconciousness

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Cont.

H/o pain,vomiting,unconciousness,headache,visual disturbances,confusion,malocclusion.

H/o amount of bleeding-from extraoral wound,intraoral wound,nose,ear.

Blood group of patient

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Glasgow coma scale

Eye opening-(e)4.opens eye spontaneously3.opens eyes to voice2.opens eyes to pain1.no eye opening

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Cont.

Motor response(m)6.obeys commands5.localizes pain4.withdraws to pain3.abnormal flexor response2.abnormal extensor response1.no movement

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Cont.

Verbal response(v)5.appropriate & oriented4.confused conversation3.inappropriate words2.incomprehensible sounds1.no sounds

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Clinical examination of maxillofacial injuries

Extraoral examinationPatient`s face is gently washed with warm

saline or water prior to examination.Inspection Length, breadth & depth of soft tissue wound

is measured.Nose & ear are inspected for bleeding or csf

leak.

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Cont.

Periorbital edema,ecchymosis,subconjunctival hemorrhage are noticed.

Bruise behind ear-battle`s sign indicates skull #.

If patient is concious, vision is tested in both the eyes.pupillary reactionto light,diplopia are noted

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Cont.

Motor function of facial &masticatory muscles are noted.

Intranasal laceration, septum deviation are noted.

Palpation Palpation is started at the back of the head

for wounds & bony injuries.

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Cont.

Then the palpation is done in the forehead, the fingers are kept in the midline & go sideways over supraorbital rims,infraorbital rims,zygomatic bones & arch.

Areas of tenderness,step deformities or abnormal mobility are noted.

Nasal bridge palpation is started from the top till the nasal tip.

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Cont.

CSF leak may form a` halo ` effect on pillow or bed sheets-ring test.since CSF is more viscous it forms the central circle encircled by blood.CSF will not stiffen the cloth whereas other secretions do so.

TMJ evaluation is done by placing the index fingers on preauricular area or on the external auditary meatus.all movements are checked.

Palpate the inferior border,posterior border for tenderness & deformity

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Intraoral examination

Inspection Oral cavity is thoroughly irrigated prior to

inspectionmouth wash can be used.Restriction of oral opening, gagging of

occlusion,lacerations,ecchymosis,damage to teeth & alveolus are noted.

Buccal & lingual sulci are inspected for wound,ecchymosis,sublingual hematoma

Loose teeth, occlusion are noted.

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Cont.

Step deformity in dental arch is noted.Palatal mucosa is inspected for tear &

bleeding.Palpation Buccal & lingual sulci are palpated for

tenderness, crepitus & mobility of teeth.Mandible is palpated bimanually & unnatural

mobility is noted.

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Cont.

For assessing maxillary mobility,patient`s head is stabilized using one hand over the forehead & with thumb & fore finger of other hand maxilla is grasped with firm pressure to elicit maxillary mobility.

Rock the maxillary alveolar segments to detect fractures of alveolus or split in palate.

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Radiologic examination

For # of middle 1/3 of facePA view skullWater`s viewLateral view skullSubmentovertex view

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Cont.

For zygomaticomaxillary complex #Water`s viewSubmentovertex viewCt scan Pa view

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Cont.

For # of mandibleOPGRight & left lateral oblique view of mandiblePA view mandibleOcclusal viewIOPA 

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Basic principles to be followed for preservation of life in a trauma patient

Maintenance of patency of airwayBleeding controlMaintenance of circulation

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Maintenance of airway

Position of the patient:-supine with neck extended or head turned sideways.

Oropharyngeal toilet:-all blood clot,sliva thick mucous, friegn bodies should be cleared by digital exploration or by using cotton swabs.

Suction:-to clear nose,oral cavity &throat.

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Cont.

Anterior traction of tongue:-tongue is pulled out & is held in position by tongue suture or towel clip.

Restoration of position of soft palate:-by disimpaction of maxilla.it is done by placing index & middle finger hooking behind the soft palate & thumb on the alveolus in the incisor region.head is stabilized with the other hand over the forehead.anterior & downward traction will bring maxilla to normal position.

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Cont.

Mouth to mouth breathingOro or nasopharyngeal tubesTracheostomy

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Bleeding control

Compression dressingMajor vessels are clamped or ligated.Soft tissue wounds are sutured.Deep wounds are packed with guaze.Nasal bleeding is stopped by using ribbon

guaze soaked in 1:1000 adrenaline.

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Maintenance of circulation:-

If the patient is in shock,iv fluids are started to restore the blood volume.

After crossmatching blood transfusion is started.

Pulse,resp.rate,bp should be monitored.Control infection by antibiotics & anti-

inflammatory analgesics through iv route.Tt is given.Adequate nutrition is given.

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Management of soft tissue injuries

Abrasions Caused by frictional violence.It is presented as raw bleeding areas.Through cleaning is done with profuse saline

irrigation.Remove the foreign materials.Gentle scrubbing is done with soft brush to

remove sticky material.Topical application of antibiotic ointment with

compression dressing is given

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Cont.

Superficial abrasions are covered with topical antibiotic & is left open

Contusion Caused by a blow or fall against a hard or

blunt object.Blood extravasates in subcutaneous tissue

leading to bluish area or bruise.Application of ice pack will help to stop

further extravasation .

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Cont.

Hematoma It is the localized collection of blood in

subcutaneous or intramuscular or submucosal space.

It may be associated with fracture or rupture of vessels.

Most of them are reabsorbed.Persistant hematomas may require incision &

drainage.Antibiotic coverage is given to prevent

infection of hematoma.

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Cont.

Lacerations Here tearing of mucosa or skin is seen.There may be associated injury to

vessels,nerves,muscles & bone.Thorough cleaning,minimum

debridement,removal of foreign bodies & proper suturing is done.

Suturing is done in multiple layers

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Cont.

Incised woundsCaused by sharp objects.They are clearcut, gaping,bleeding wounds

with minimum contamination.The wound is cleaned,bleeding is arrested.Wound is closed by primary intensionPenetrating & punctured woundsCaused by pointed objects.Externally they appear small, but they may be

deep penetrating endangering vital organs.

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Cont.

Crushed wounds:-Crushing of the parts with laceration is seen.Crushing of musculature is seen.Damage to blood vessels & nerves may be

seen.Bone may be shattered.There may be loss of soft or hard tissues.

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Cont.

Gunshot injuries:-They can be

Penetrating wound-missile is retained in the wound Perforating wound-missile produces another wound

of exit. Avulsive wounds-large portion of soft tissue or bone

is desroyed.

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Supportive therapy of soft tissue wounds

Drains:-for deeper wounds in oral cavity drains may be placed b/w sutures .it is removed after 2 to 4 days.

Dressings:-antibiotic ointment with dry guaze dressing is changed in every 48hrs.sutuires are removed on 5th or 7th day.

Prevention of infection:-sterile technique & supportive antibiotic therapy.

Prophylaxis against tetanus

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Factors causing failure of wound healing

Too tight suturing.Inadequqte pressure dressing.Oral contamination of wound.Secondary haemorrhage.Inadequate antibiotic therapy.Rough handling of wounds.Foreign body inclusion.Compromised vascularity.

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Cont.

Infection.Constant movement.Radiation.Old age.AnemiaLack of vit.c.DiabetesHapatitisSteroid therapy

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Basic principles of management of fracture

Reduction FixationImmobilization

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Reduction

It is the restoration of fractured fragments to their original position.

Reduction is brought about by closed reduction or open reduction.

Closed reductionIt can be carried out by manipulation or by

traction.No surgical intervention is needed for closed

reduction.Occlusion of teeth is used as the guiding factor.

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Cont.

Reduction by manipulationDone when the fragments are adequately

mobile witout much overriding or impaction & patient comes immediately comes after trauma.

Digital or hand manipulation is used for reduction.

Disimpaction forceps or bone holding forceps can be used.

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Cont.

Reduction by tractionPrefabricated arch bars are attached to

maxillary & mandibular arches by interdental wiring.

The fractured fragments are subjected to gradual elastic traction by placing elastics from upper to lower arch.

Open reductionSurgical reduction that allows visual

identification of fractured fragments.

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Fixation

Fractured fragments are fixed to prevent displacement & for achieving proper approximation.

Direct skeletal fixation :-by plates or intraosseous wiring.

Indirect skeletal fixation:-by arch bar or intermaxillary fixation.

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Immobilization

The fixation device is retained to stabilize the reduced fragments until a bony union takes place.

For maxillary # 3 to 4 weeks immobilization is enough.

For mandible # 4 to 6 weeks immobilization.In condylar # 2 to 3 weeks immobilization to

prevent ankylosis. 

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Arch bars

It has hooks incorported on the outer surface with malleable stainless steel metal strip

The bar is cut to the length of dental arch.Arch bar is fixed to both the arches.On the upper jaw the hooks are arranged in

upward direction.Archbar is adapted by bending the archbar

starting from the buccal side of last tooth.

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Cont.

The arch bar is fixed to the tooth with 26 guage wire,one end of wire is above & the other below the arch bar.

The twisting of the wire is done in clockwise manner.

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46

Bone plate osteosynthesis

Indications If imf is contraindicatedEdentulous patients with loss of bone segments.If early mobilization of joint is required as in

condylar #Contraindications Heavily contaminated # with active infection &

discharge.Badily comminuted #.In mixed dentition period.Presence of gross pathologies in bone.

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Cont.

Precautions Strict aseptic procedure is required.Patient should be kept on preoperative

antibiotics.Plates and screws should be of same metal.Minimum 2 screws should be used on each

side.The drill bit should be perpendicular to the

cortex.Patient should maintain good oral hygiene.

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Cont.

Procedure The intrafragmentary gap is less than 0.8mm

.Occlusal relationship is checked prior to

screw fixation.Plates & screws are made up of stainless

steel or titanium & is removed later.In compression bicortical screw system:-the

outer oblique holes produce additional compression.

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Cont.

In monocortical noncompression screw system (miniplte osteosynthesis):-stability is achieved by perfect anatomic reduction & intrafragmentary approximation without compression.

Miniplates are 2cm long.0.9 mm thick &6mm wide.

Screws have a thickness of 3.3mm. The screws should be self tapping.

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