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  • 1. Facial Fractures – Mandible and Frontal Bones Dale Reynolds, MD UT Houston Plastic & Reconstructive Surgery
  • 2. Facial Fractures
    • Phases
      • Emergency Treatment
        • Airway
          • Edema
          • Teeth
          • Blood
          • FB
          • Mandible fracture  tongue to pharynx
          • Stridor, hoarseness, retraction, drooling
          • ETT
          • Tracheostomy
            • Long term IMF
          • Cricothyroidotomy
  • 3. Facial Fractures
    • Hemorrhage
      • Anterior cranial fossa
      • Midface
      • Lacerations
      • Nasal
        • Nasal, zygomatic, orbital, frontal, NOE, maxillary
      • Reduction (IMF)
      • Anterior/ posterior packing x 24-48 hrs
      • Compression dressing
      • Embolization
      • Bilateral external carotid/ superficial temporal ligation
      • Blood factor replacement
  • 4. Facial Fractures
        • Aspiration
          • Low threshold for ETT
        • Other
          • Eye
          • Brain
          • Spine
  • 5. Facial Fractures
      • Early injury care
        • History
        • PE
          • Nerves, vision, intraoral, nasopharyngeal, dentition
        • Radiographs
        • Lacerations
        • IMF
        • Impressions
  • 6. Facial Fractures
      • Classification
        • Anatomy
        • Closed v. open
        • Le Fort
      • Radiography
        • CT v. x-rays
      • Occlusion/ dentition
  • 7. Facial Fractures
    • Mandible
      • Anatomy
  • 8. Facial Fractures
    • Mandible
      • Anatomy
  • 9. Facial Fractures
    • Mandible
      • Anatomy
  • 10. Facial Fractures
    • Mandible
      • Anatomy
  • 11. Facial Fractures
    • Mandible
      • Most common facial fracture after nasal
      • 10-25% of all facial fractures
      • Body> angle> condyle> parasymphysis> other
      • M: F = 2: 1
      • 58% multiple (93% , 3 fx)
      • Preinjury relationships
      • Stable bony union
      • Facial proportions
      • Avoid complications
  • 12. Facial Fractures
    • Mandible
      • History
        • Previous trauma
        • Previous baseline
        • Pre-injury photo
  • 13. Facial Fractures
    • Mandible
      • PE
        • Crepitance
        • Symmetry
        • Tenderness
        • Oral/ dental – missing teeth
        • Step offs
  • 14. Facial Fractures
    • Mandible
      • Radiography
        • Panorex
        • CT
        • Plain films
          • PA, Towne’s, R and L lateral oblique views (mandibular series)
  • 15. Mandible
    • Treatment
      • Restore form and function
        • Occlusion, TMJ function, cosmesis
      • ORIF
        • Exact anatomic reduction
        • Allows early resumption of mandibular function
  • 16. Mandible
  • 17. Mandible
    • Treatment
      • Closed
      • Dependent on splinting to maxilla to restore centric occlusion (maximal intercusspation)
      • If inadequate number of teeth,Gunning splint may be needed for IMF
  • 18. Mandible
    • Treatment
      • Open
        • Accurate reduction
          • Within 2 weeks
          • If maxilla cannot be used then mandible first or splints
        • Avoid prolonged IMF
          • Traumitizes gingiva
          • Impairs oral hygiene  periodontal disease
          • Uncomfortable
          • Forces can alter tooth position and periodontal attachments
          • Great aspiration risk
          • Contraindication in COPD, seizure d/o, impaired MS
          • Articular surfaces under compression cause pressure necrosis
  • 19. Mandible
    • ORIF
      • Lag screw – Anterior
  • 20. Mandible
    • ORIF
      • Reconstruction plate – Comminuted body
  • 21. Mandible
    • ORIF
      • Two plate/ tension band – Angle
  • 22. Mandible
    • ORIF
      • Dynamic compression plate - Condyle
  • 23. Mandible
    • Treatment
      • Contraindications to open
        • Not required
        • Not candidate
      • Rarely needed in children
        • Simple
        • Heal quickly
        • Occlusion less established
  • 24. Facial Fractures
  • 25. Mandible
    • Treatment by type
      • Simple
        • CR + IMF x 8 weeks if reliable (unreliable avoid IMF and open)
  • 26. Mandible
    • Treatment by type
      • Complex
        • Multiple or segmental
          • Often interosseous wires/ reduction clamps/ temporary mini-plates help
        • Inferior “butterfly” segment
          • Difficult to reduce
  • 27. Mandible
    • Treatment by type
      • Complex
        • Bilateral fracture each hemi-mandible
          • Simultaneous reduction may be required to avoid magnification of discrepancy
          • Arch bars and IMF may worsen
        • Anterior fracture with one or both condyles
          • Consider reducing one or both condyles first if difficult to control flaring the inferior border
        • Unilateral segmental fracture in one hemi-mandible
          • Close fractures – two plates
          • Separated fractures – long spanning plate
  • 28. Mandible
    • Treatment by type
      • Complex
        • Comminuted
          • High energy – GSW, SGW, MVC
          • Easy to devitalize small fragments
          • Difficult to accurately reduce
          • Large reconstruction plate may be required
          • Temporary external fixator may be used if condition of patient or soft tissue requires
          • Bone graft for extensive loss
          • Pre-treatment infection: Debride small fragments
          • Post-treatment infection: FB (bone or screw)
  • 29. Mandible
    • Treatment by type
      • Complex
        • Edentulous
          • Atrophied and osteopenic  poorer healing
          • Early atherosclerosis (15 years) of inferior alveolar artery  20% non-union
          • Simple and undisplaced  pureed diet and obs
          • Use dentures or splints
        • Fracture with bony defect
          • Rigid fixation with spanning reconstruction plate
          • Bone graft/ flap within 5 years
          • Soft tissue repair and IMF or ex fix until ready
  • 30. Mandible
    • Treatment
      • Infection
        • More common if delayed care
        • Abx, debridement
        • Fracture line may resorb and form gaps – larger plates
        • Extreme cases may require external fixator with secondary ORIF +/- graft
  • 31. Mandible
    • Treatment
      • Children
        • Most need CR + immobilization (single arch bar or lingual splint) x 2 weeks
        • Conical shape makes arch bars less useful
        • Indications for ORIF
          • Unstable fractures
          • Not amenable to CR
          • Bilateral fractures with gross instability
        • Use unicortical plates
        • Remove 6-8 weeks later
  • 32. Mandible
    • Treatment
      • Children
        • Condyle is growth center of mandible
        • Trauma can cause hemarthrosis  ankylosis
        • Intracapsular fractures that do not alter the centric occlusion should not be immobilized to avoid ankylosis which can occur >12 months later and requires aggressive treatment
        • Unilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elastics
        • Displaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks
  • 33. Mandible
    • Treatment
      • By Location
        • Alveolar Process (1%)
          • Remove if devitalized o/w IMF or splint
        • Symphysis (5.8%)
          • Often associated with condylar fractures
          • Significant forces cause lateral flaring of posterior segments (often worse with IMF)
        • Parasymphysis (11.6%)
          • Often associated with contralateral fractures
          • Mental nerve
          • Burr/ osteotome may help lessen anterior curvature
  • 34. Mandible
    • Treatment
      • By Location
        • Body (31.9%)
          • May require external approach
          • Bi-cortical plates placed beneath mental canal
        • Angle (27.5%)
          • May require external approach
          • Often associated with contralateral
          • Highest complication rate due to third molar teeth and displacing forces
  • 35. Mandible
    • Treatment
      • By Location
        • Ramus (2.5%)
          • Usually require extraoral approach
          • Often stable due to splinting effect of masseter-medial pterygoid muscle sling unless displacement causes vertical shortening (telescoping)
        • Coronoid process (1.8%)
          • Soft diet usually enough
          • Severe pain may require brief IMF
  • 36. Mandible
    • Treatment
      • By Location
        • Condyle (23.8%)
          • Proximal segment can undergo AVN
          • Intra-articular fractures: Very difficult ORIF, OA is common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elastics
          • Condylar neck: Anteromedial displacement of proximal segment by lateral pterygoid, usually treated with IMF x 6 weeks, ORIF if joint capsule is thought to be involved
  • 37. Mandible
    • Treatment
      • By Location
        • Condyle
          • ORIF
            • Displaced in to middle cranial fossa
            • FB within joint
            • Lateral extra-capsular displacement of condyle
            • Displacement blocking opening or closing
            • Posterior vertical shortening of mandible with open bite after 2 week IMF trial
          • Relative
            • Bilateral associated with unstable midface fractures
            • Bilateral edentulous without splint
  • 38. Mandible
    • Postoperative care
      • +/- Abx, airway control with IMF (wire cutters), HOB (secretions) + ice pack for edema
    • Diet
      • CLD  blenderized, 48 o IVF, 15 lb wt loss
    • Splints/ IMF
      • Oral hygiene (peridex, H2O2, brush), remove wax
    • Oral washouts
      • Release IMF q 3-5 days if needed
  • 39. Mandible
    • Centric occlusion
      • Remove IMF to assess ORIF
    • Therapeutic rehabilitation
      • Regain strength and mobility, PT if severe (prolonged IMF or condyle fracture)
      • Dental treatment (missing teeth)
    • Complications
      • Malocclusion, malunion, non-union, hardware exposure, infection, non-compliance
  • 40. Mandible
    • Teeth in fracture line
  • 41. Facial Fractures
    • Frontal bone anatomy – 7 bones
  • 42. Facial Fractures
    • Frontal bone anatomy
  • 43. Facial Fractures
    • Frontal sinus anatomy
      • Middle meatus
  • 44. Facial Fractures
    • Frontal Sinus
      • MVC - ¾
      • Assaults – ¼
      • 2-3 x force to fracture lower frontal sinus
      • Other injuries associated (1/4 die in 14d)
      • Rare in children
  • 45. Facial Fractures
    • Frontal Sinus Fracture
      • Signs
        • Rhinorrhea
        • Step-off
        • Supraorbital anesthesia
        • Subconjunctival hematoma
        • Subcutaneous crepitance
  • 46. Facial Fractures
    • Frontal Sinus Fracture
      • Diagnosis
        • Plain films
        • CT
  • 47. Facial Fractures
    • Frontal sinus fractures
      • Anterior Table (Thick)
        • Displaced  ORIF
        • Blockage of nasofrontal duct (methylene blue)
          • Remove mucosa
          • Bone graft nasofrontal ducts, fill space
          • Elevate and fixate bone
      • Posterior Table (Thin)
        • Comminuted  Cranialize
        • Displaced greater than one wall thickness  ORIF
  • 48. Facial Fractures
    • Frontal Sinus Fracture
      • Complications (Posterior > anterior)
        • Acute
          • Epistaxis
          • CSF leak
          • Meningitis
          • Intracranial injury
          • Hematoma
        • Subacute
          • Mucocele
          • Sinusitis
        • Chronic
          • Osteomyelitis
          • Abscesses
  • 49. END

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