MAXILLOFACIAL INJURIESMAXILLOFACIAL INJURIES

INTRODUCTIONINTRODUCTION

A fracture may be defined as a sudden violent A fracture may be defined as a sudden violent solution of continuity of bone and may be solution of continuity of bone and may be complete or incomplete in character.complete or incomplete in character.

May be from May be from 1)Direct violence 1)Direct violence 2)Indirect violence 2)Indirect violence 3)Excessive muscular contraction. 3)Excessive muscular contraction.

Factors influencing fracture and Factors influencing fracture and displacementdisplacement

1. Degree of force.

2. Resistance offered by facial bones.

3. Direction of force.

4. Point of application of force.

5. Cross sectional area of object.

6. Attached muscles.

Basic principles of treatmentBasic principles of treatment

1.Preservation of life.1.Preservation of life. 2.Restoration of appearance. 2.Restoration of appearance. 3.Maintenance of function. 3.Maintenance of function.

Treatment starts with……..Treatment starts with……..

1.Maintenance of airway. 1.Maintenance of airway. 2.Control of hemorrhage. 2.Control of hemorrhage. 3.Control of pain. 3.Control of pain.

FRACTURES OF THE MANDIBLEFRACTURES OF THE MANDIBLETYPES OF FRACTURETYPES OF FRACTURE::

1.Simple1.Simple

2.Compound 2.Compound

3.Comminuted 3.Comminuted

4.Complicated 4.Complicated

5.Impacted 5.Impacted

6.Green stick 6.Green stick

7.Pathological…7.Pathological… ( (as in generalized skeletal diseases, cysts of jaw,osteomyelitis and as in generalized skeletal diseases, cysts of jaw,osteomyelitis and neoplasms.)neoplasms.)

COMMON SITESCOMMON SITES

Sub condylarSub condylarAngle of the mandibleAngle of the mandibleSymphysis menti regionSymphysis menti regionPremolar regionPremolar regionRamus of the mandibleRamus of the mandibleCoronoid process.Coronoid process.

May be…….May be……. Single unilateral Single unilateral Double unilateral Double unilateral Double bilateral Double bilateral Multiple. Multiple.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS1.1. History of injury to that areaHistory of injury to that area2.2. PainPain3.3. SwellingSwelling4.4. Interference with functionInterference with function5.5. Abnormal mobilityAbnormal mobility6.6. MalocclusionMalocclusion7.7. DeformityDeformity8.8. CrepitusCrepitus9.9. Absence of transmitted movements.Absence of transmitted movements.

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

1.Restoration of fragments to the correct position.1.Restoration of fragments to the correct position.2.Maintenance of fragments in their anatomical 2.Maintenance of fragments in their anatomical

relationship.relationship.3.Prevention of infection.3.Prevention of infection.

METHODS OF TREATMENTMETHODS OF TREATMENT

1.Reduction….closed \ open1.Reduction….closed \ open2.Fixation…….internal \ external2.Fixation…….internal \ external3.Immobilization.3.Immobilization.

INTERNAL FIXATIONINTERNAL FIXATION1.1. Indirect/direct interdental wiringIndirect/direct interdental wiring

2.2. Arch barArch bar

3.3. Cap splintCap splint

4.4. Gunning splintGunning splint

5.5. Trans osseous wiringTrans osseous wiring

6.6. Bone platingBone plating

7.7. Intra medullary fixationIntra medullary fixation

8.8. Bone screws, staples.Bone screws, staples.

EXTERNAL FIXATIONEXTERNAL FIXATION

1.1. Skeletal pin fixationSkeletal pin fixation2.2. Circumferential wiringCircumferential wiring

DEFINITIVE CLINICAL DEFINITIVE CLINICAL EXAMINATIONEXAMINATION

1.1. History of injuryHistory of injury2.2. Level of consciousnessLevel of consciousness3.3. Nature of injuriesNature of injuries4.4. Local exam of soft and hard tissues… Local exam of soft and hard tissues…

and intra oral exam.and intra oral exam.

DIAGNOSTIC RADIOGRAPHYDIAGNOSTIC RADIOGRAPHY Occipito frontal 25 degreesOccipito frontal 25 degrees Fronto occipital 25 degreesFronto occipital 25 degrees Occipito mental 30 degreesOccipito mental 30 degrees Ant-post 30 degrees(Towne`s view) for middle thirdAnt-post 30 degrees(Towne`s view) for middle third

FOR MANDIBLE,FOR MANDIBLE,

Post-ant 10 degreesPost-ant 10 degrees Lat obliqueLat oblique OPGOPG Tomography of TMJTomography of TMJ

A SYSTEM FOR ANALYSIS OF A SYSTEM FOR ANALYSIS OF OCCIPITO MENTAL PROJECTIONOCCIPITO MENTAL PROJECTION

Most useful for study of fractures of middle 3Most useful for study of fractures of middle 3rdrd.. Consists of 4 curvilinear lines of interpretation…Consists of 4 curvilinear lines of interpretation…

by Mc Gregor and Campbell(1950)by Mc Gregor and Campbell(1950)

1)Zygomatico-frontal suture on one side superior 1)Zygomatico-frontal suture on one side superior orbital margin~glabella~s.o margin orbital margin~glabella~s.o margin glabella~zygomatic frontal suture of the opposite glabella~zygomatic frontal suture of the opposite side.side.

A SYSTEM FOR ANALYSIS OF A SYSTEM FOR ANALYSIS OF OCCIPITO MENTAL PROJECTIONOCCIPITO MENTAL PROJECTION

2)Zygomatic tubercle~arch~zygomatic 2)Zygomatic tubercle~arch~zygomatic bone~inferior orbital margin~across frontal bone~inferior orbital margin~across frontal process of maxilla,lateral wall of nose~opposite process of maxilla,lateral wall of nose~opposite side.side.

3)Condye~mandibular notch~coronoid 3)Condye~mandibular notch~coronoid process~lateral wall of antrum~medial wall of process~lateral wall of antrum~medial wall of antrum~nasal floor~opposite side.antrum~nasal floor~opposite side.

4)Occlusal curve of upper and lower teeth.4)Occlusal curve of upper and lower teeth. 5)Lower border of mandible.5)Lower border of mandible.

REDUCTIONREDUCTION

1.1. By closed method under LA..when not By closed method under LA..when not much displacement.much displacement.

2.2. Open method under GA or LA…when Open method under GA or LA…when grossly displaced.grossly displaced.

3.3. Slow traction by applying elastic Slow traction by applying elastic bands.bands.

FIXATIONFIXATIONNo gross displacement-fixed to the upper jaw by inter dental No gross displacement-fixed to the upper jaw by inter dental

wiring-upper teeth used as guide.Eg:eyelet wiring..here 26 wiring-upper teeth used as guide.Eg:eyelet wiring..here 26 to 28 ss wire used.to 28 ss wire used.

1.1. Standard eyelets are made and applied to upper and lower Standard eyelets are made and applied to upper and lower teeth.teeth.

2.2. Teeth are kept in occlusionTeeth are kept in occlusion3.3. Tie wires are applied through the eyelets.Tie wires are applied through the eyelets.

THIS IS CALLED INTER MAXILLARY FIXATION.THIS IS CALLED INTER MAXILLARY FIXATION.

SOMETIMES…ARCH BARS ARE APPLED.SOMETIMES…ARCH BARS ARE APPLED. …CAP SPLINTS (acrylic or metal) …CAP SPLINTS (acrylic or metal)

Incase of gross displacement. resort to open reduction and Incase of gross displacement. resort to open reduction and fixation like trans osseous wiring.fixation like trans osseous wiring.

TRANSOSSEOUS WIRING OR TRANSOSSEOUS WIRING OR OSTEOSYNTHESISOSTEOSYNTHESIS

INDICATIONSINDICATIONS::

Edentulous posterior fragment.Edentulous posterior fragment. Edentulous fractured mandible.Edentulous fractured mandible. Grossly displaced fracture.Grossly displaced fracture.

It could be done alone or with It could be done alone or with interdental wiring of upper or lower interdental wiring of upper or lower borders.borders.

SURGERY:SURGERY:Under GA or LA fractured site is exposed Under GA or LA fractured site is exposed

through sub mandibular approach. Drill through sub mandibular approach. Drill holes are made on either side of holes are made on either side of fragment and wiring is done. fragment and wiring is done. Maintaining occlusion, the wound is Maintaining occlusion, the wound is closed in layers.closed in layers.

It is immobilized by interdental wiring to It is immobilized by interdental wiring to the upper jaw.the upper jaw.

In cases where there is combined In cases where there is combined fracture of maxilla or if eyelet wiring fracture of maxilla or if eyelet wiring is not possible; maxilla is reduced is not possible; maxilla is reduced first , mandible is fixed…first , mandible is fixed…

To the head by a head cap orTo the head by a head cap orTo zygomatic boneTo zygomatic boneOr upper border of orbit by Or upper border of orbit by

suspensory wires.suspensory wires.

FRACTURE OF THE MIDDLE 3FRACTURE OF THE MIDDLE 3rdrd FACIAL SKELETONFACIAL SKELETON

It is bound superiorly by a line drawn It is bound superiorly by a line drawn across the skull from zygomatico across the skull from zygomatico frontal suture across the Fronto nasal frontal suture across the Fronto nasal and Fronto maxillary sutures to and Fronto maxillary sutures to zygomatic frontal suture of opposite zygomatic frontal suture of opposite side.side.

Inferiorly-occlusal plane of teeth Inferiorly-occlusal plane of teeth backward as far as frontal bone backward as far as frontal bone above…and body of sphenoid below.above…and body of sphenoid below.

IT IS MADE UP OF THE IT IS MADE UP OF THE FOLLOWING BONES:FOLLOWING BONES:

1.1. Two maxillaeTwo maxillae2.2. Two zygomatic bonesTwo zygomatic bones3.3. Two zygomatic processes of temporal boneTwo zygomatic processes of temporal bone4.4. Two palatine bonesTwo palatine bones5.5. Two nasal bonesTwo nasal bones6.6. Two lachrymal bonesTwo lachrymal bones7.7. The vomerThe vomer8.8. Ethmoid and its attached conchaeEthmoid and its attached conchae9.9. Two inferior conchaeTwo inferior conchae10.10. Pterygoid plates of sphenoid.Pterygoid plates of sphenoid.

Because of the relative fragility of middle 3Because of the relative fragility of middle 3rdrd facial facial skeleton, it acts as cushion for trauma directed skeleton, it acts as cushion for trauma directed towards cranium.towards cranium.

Fractures are invariably multiple.Fractures are invariably multiple. The pattern of fracture of these bones are The pattern of fracture of these bones are

markedly consistent and follows the lines of markedly consistent and follows the lines of weakness within the face described classically by weakness within the face described classically by Guerin (1866)and lefort(1901).Guerin (1866)and lefort(1901).

Involvement of brain and cranial nerves occur in Involvement of brain and cranial nerves occur in severe forms leading to dural tear, damage to severe forms leading to dural tear, damage to infra orbital and zygomatic nerves.infra orbital and zygomatic nerves.

Fracture of orbit may lead td alteration in position Fracture of orbit may lead td alteration in position of globe.of globe.

Severe nasal complex injury may lead to Severe nasal complex injury may lead to involvement of naso lachrymal duct leading to involvement of naso lachrymal duct leading to epiphora.epiphora.

CLASSIFICATION ON CLASSIFICATION ON ANATOMICAL BASISANATOMICAL BASIS

FRACTURE NOT INVOLVING OCCLUSION:FRACTURE NOT INVOLVING OCCLUSION:1)1)CENTRAL REGIONCENTRAL REGIONa) # of nasal bone/nasal septuma) # of nasal bone/nasal septum i)lat nasal injuriesi)lat nasal injuries ii)ant nasal injuriesii)ant nasal injuriesb)# of frontal process of maxillab)# of frontal process of maxillac)# type a and b…extending into Ethmoid bonec)# type a and b…extending into Ethmoid boned)# type a,b,c..extending into frontal bone d)# type a,b,c..extending into frontal bone

(frontal-orbital-nasal dislocation)(frontal-orbital-nasal dislocation)

# INVOLVING OCCLUSION:# INVOLVING OCCLUSION: LATERAL REGIONLATERAL REGION::a)Dento alveolar #a)Dento alveolar #b)Sub zygomatic fractureb)Sub zygomatic fracture i)lefort 1(low level or Guerin)i)lefort 1(low level or Guerin) i)lefort 2(pyramidal)i)lefort 2(pyramidal)c)Supra zygomatic #c)Supra zygomatic # i)lefort 3(high level or cranio facial i)lefort 3(high level or cranio facial

disjunction)disjunction)

SIGNS AND SYMPTOMS OF SIGNS AND SYMPTOMS OF MIDDLE 3MIDDLE 3rdrd FRACTURE FRACTURE

1.1. Pain and swelling of facePain and swelling of face2.2. Derangement of occlusion with gaggingDerangement of occlusion with gagging3.3. Ecchymosis in buccal sulcusEcchymosis in buccal sulcus4.4. Step deformity of infra orbital marginsStep deformity of infra orbital margins5.5. Mobility of mid faceMobility of mid face6.6. Anesthesia or parasthesia of cheekAnesthesia or parasthesia of cheek7.7. Cerebrospinal rhinorrhoeaCerebrospinal rhinorrhoea8.8. Tenderness and deformity of zygomatic Tenderness and deformity of zygomatic

archesarches9.9. Lengthening of faceLengthening of face10.10. Depression of ocular levels-diplopiaDepression of ocular levels-diplopia

MANAGEMENT OF PATIENTMANAGEMENT OF PATIENT1.1. Immediate treatment should be directed towards Immediate treatment should be directed towards

patient's general medical condition.patient's general medical condition.2.2. Obstruction to airway should be relieved esp in Obstruction to airway should be relieved esp in

semi and unconscious patients.semi and unconscious patients.3.3. Bleeding should be arrested and head injury, Bleeding should be arrested and head injury,

cranium should be palpated fop evidence of cranium should be palpated fop evidence of lacerations and bony damage.lacerations and bony damage.

4.4. Level of consciousness determined.Level of consciousness determined.5.5. Eyes to be examined for any physical injury to the Eyes to be examined for any physical injury to the

globe, vision ,pupil size and reaction to light.globe, vision ,pupil size and reaction to light.6.6. Exam for any visceral injury or # chest wall or Exam for any visceral injury or # chest wall or

pelvispelvis7.7. Soft tissue lacerations to be sutured within 1-8 hrs.Soft tissue lacerations to be sutured within 1-8 hrs.

TREATMENT OUTLINETREATMENT OUTLINE

Specialized instruments are used:Specialized instruments are used: For reduction and disimpaction if For reduction and disimpaction if

maxillary # - Rowe's maxillary maxillary # - Rowe's maxillary disimpaction forceps.disimpaction forceps.

For nasal # _ Ash septal forcepsFor nasal # _ Ash septal forceps For zygoma # - Rowe's zygomatic For zygoma # - Rowe's zygomatic

elevators.elevators.

FIXATIONFIXATION EXTERNAL:EXTERNAL:1.1. Interdental wiringInterdental wiring2.2. Cap splints with locking platesCap splints with locking plates3.3. Acrylic plates secured by per alveolar Acrylic plates secured by per alveolar

wiringwiring4.4. Fixed to the craniumFixed to the cranium a)cranio maxillarya)cranio maxillary

b)cranio mandibular b)cranio mandibular c)zygomatico mandibular c)zygomatico mandibular

INTERNAL:INTERNAL:1.1. Zygomatico frontalZygomatico frontal2.2. Zygomatico maxillaryZygomatico maxillary3.3. ZygomaticZygomatic4.4. Palatal processPalatal process5.5. Fronto nasalFronto nasal6.6. Adam's wiring by direct suspension toAdam's wiring by direct suspension to

a)pyriform fossaa)pyriform fossab)zygomatic buttressb)zygomatic buttressc)zygomatic archc)zygomatic archd)infra orbital rimd)infra orbital rime)zygomatic process of frontal bonee)zygomatic process of frontal bone

7.7. Tran fixation- k wire and stein man pinsTran fixation- k wire and stein man pins

COMPLICATIONSCOMPLICATIONS

1.1. Post traumatic head achePost traumatic head ache2.2. Dural adhesionsDural adhesions3.3. Traumatic diabetes insipidusTraumatic diabetes insipidus4.4. Rupture of olfactory nerve-anosmiaRupture of olfactory nerve-anosmia5.5. Stretching of third and fourth cranial Stretching of third and fourth cranial

nerves-ocular palsynerves-ocular palsy6.6. Damage to fifth nerve-anesthesiaDamage to fifth nerve-anesthesia

ORBITAL : diplopia or loss of visionORBITAL : diplopia or loss of visionANTRAL : haematoma , ANTRAL : haematoma ,

emphysema,oro antral or nasal fistulaemphysema,oro antral or nasal fistulaDENTAL :loss of sensation ,anterior DENTAL :loss of sensation ,anterior

open byteopen byteGENERAL :flattening of face ,increase GENERAL :flattening of face ,increase

in inter orbital width, mongoloid in inter orbital width, mongoloid app ,increase in vertical height.app ,increase in vertical height.

THANK YOUTHANK YOU