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Maxillo facial injuriesDepartment of dentistryTata Main HospitalDr K V Sebastian,[object Object],KVS,[object Object]
KVS,[object Object],Maxillofacial injuries,[object Object]
Learning Objectives,[object Object],To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head & spinal injuries.,[object Object],Method of examining facial injuries.,[object Object],Diagnosis & principles of management of facial injuries,[object Object],KVS,[object Object],3,[object Object]
Anatomy,[object Object],KVS,[object Object]
Anatomy,[object Object],KVS,[object Object]
Causes,[object Object],Road traffic accidents,[object Object],Intentional violence,[object Object],Sporting activities,[object Object],KVS,[object Object]
Pathophysiology,[object Object],High Impact:,[object Object],Supraorbital rim – 200 G,[object Object],Symphysis of the Mandible –100 G,[object Object],Frontal – 100 G,[object Object],Angle of the mandible – 70 G,[object Object],Low Impact:,[object Object],Zygoma – 50 G,[object Object],Nasal bone – 30 G,[object Object],KVS,[object Object]
Severity,[object Object],@60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.,[object Object],20-50% concurrent brain injury.,[object Object],1-4% cervical spine injuries.,[object Object],Blindness occurs in 0.5-3% ,[object Object],KVS,[object Object]
Assessment	,[object Object],Based on,[object Object],Targeting care: Glasgow Coma Scale (GCS),[object Object],Predicting outcome: Abbreviated Injury Scale (AIS) and Injury Severity Score(ISS),[object Object],Assessing critically injured patients: APACHE II,[object Object],KVS,[object Object]
Initial hospital care,[object Object],Triage the causalities(sorting for prioritization),[object Object],A:	airway with cervical spine control,[object Object],B:	breathing and ventilation,[object Object],C: 	circulation and hemorrhage control,[object Object],D:	disability due to neurologic deficit,[object Object],E:	exposure and environment control,[object Object],KVS,[object Object]
Clinical effects,[object Object],Injuries to facial skeleton -> ,[object Object],       Immediate airway obstruction,[object Object],      delayed airway obstruction,[object Object],KVS,[object Object]
Immediate airway obstruction,[object Object],    inhalation of tooth fragments,[object Object],   accumulation of blood & secretions ,[object Object],   loss of control of tongue in unconscious/  semiconscious pt. ->,[object Object],KVS,[object Object]
Emergency ManagementAirway Control,[object Object],Control airway:,[object Object],Chin lift.,[object Object],Jaw thrust.,[object Object],Oropharyngeal suctioning.,[object Object],Manually move the tongue forward.,[object Object],Maintain cervical immobilization,[object Object],KVS,[object Object]
Emergency ManagementIntubation Considerations,[object Object],Avoid nasotracheal intubation:,[object Object],Nasocranial intubation,[object Object],Nasal hemorrhage,[object Object],Avoid Rapid Sequence Intubation:,[object Object],Failure to intubate or ventilate.,[object Object],Consider awake intubation.,[object Object],Sedate with benzodiazepines. ,[object Object],KVS,[object Object]
Emergency ManagementIntubation Considerations,[object Object],Consider fiberoptic intubation if available. ,[object Object],Alternatives include percutaneous transtracheal ventilation and retrograde intubation.,[object Object],Be prepared for cricothyroidotomy.,[object Object],KVS,[object Object]
Emergency ManagementHemorrhage Control,[object Object],Maxillofacial bleeding:,[object Object],Direct pressure.,[object Object],Avoid blind clamping in wounds.,[object Object],Nasal bleeding:,[object Object],Direct pressure.,[object Object],Anterior and posterior packing.,[object Object],Pharyngeal bleeding:,[object Object],Packing  of the pharynx around ET tube.,[object Object],KVS,[object Object]
History,[object Object],Obtain a history from the patient, witnesses and or EMS,[object Object],Specific Questions:,[object Object],Was there LOC? If so, how long?,[object Object],How is your vision?,[object Object],Hearing problems?,[object Object],KVS,[object Object]
History,[object Object],Specific Questions:,[object Object],Is there pain with eye movement?,[object Object],Are there areas of numbness or tingling on your face?,[object Object],Is the patient able to bite down without any pain?,[object Object],Is there pain with moving the jaw?,[object Object],KVS,[object Object]
Clinical examination,[object Object],ATLS standard approach,[object Object],Inspection,[object Object],Palpation,[object Object],Visual examination,[object Object],Eye movement,[object Object],Diplopia,[object Object],Pupil reaction,[object Object],19,[object Object]
Physical Examination,[object Object],Inspection of the face for asymmetry.,[object Object],Inspect open wounds for foreign bodies.,[object Object],Palpate the entire face.,[object Object],Supraorbital and Infraorbital rim,[object Object],Zygomatic-frontal suture,[object Object],Zygomatic arches,[object Object],KVS,[object Object]
Physical Examination,[object Object],Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.,[object Object],Inspect nasal septum for septal hematoma, CSF or blood.,[object Object],Palpate nose for crepitus, deformity and subcutaneous air.,[object Object],Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone. ,[object Object],KVS,[object Object]
Physical Examination,[object Object],Check facial stability.,[object Object],Inspect the teeth for malocclusions, bleeding and step-off.,[object Object], Intraoral examination: ,[object Object],Manipulation of each tooth.,[object Object],Check for lacerations.,[object Object],Stress the mandible.,[object Object],Tongue blade test.,[object Object],Palpate the mandible for ,[object Object],tenderness, swelling and step-off.,[object Object],KVS,[object Object]
Fractures of Facial Skeleton,[object Object],Upper third – above the eyebrows – involves frontal sinuses & supraorbital ridges,[object Object],Middle third – above the mouth,[object Object],    Le Fort I , II , II,[object Object],Lower third -- Mandible,[object Object]
Imaging of Facial Trauma,[object Object],Frontal Sinus/ Bone FracturesDiagnosis,[object Object],Radiographs:,[object Object],Facial views should include ,[object Object],Waters, Caldwell and lateral projections.,[object Object],Caldwell view best evaluates ,[object Object],the anterior wall fractures.,[object Object],KVS,[object Object]
Frontal Sinus/ Bone FracturesDiagnosis,[object Object],CT Head with bone windows:,[object Object],Frontal sinus fractures. ,[object Object],Orbital rim and nasoethmoidal fractures.,[object Object],R/O brain injuries or intracranial bleeds.,[object Object]
Naso-Ethmoidal-Orbital Fracture,[object Object],Fractures that extend into the nose through the ethmoid bones.,[object Object],Associated with lacrimal disruption and dural tears.,[object Object],Suspect if there is trauma to the nose or medial orbit.,[object Object],Patients complain of pain on eye movement.,[object Object]
Naso-Ethmoidal-Orbital Fracture,[object Object],Clinical findings:,[object Object],Flattened nasal bridge or a saddle-shaped deformity of the nose.,[object Object],Widening of the nasal bridge (telecanthus),[object Object],CSF rhinorrhea or epistaxis.,[object Object],Tenderness, crepitus, and mobility of the nasal complex.,[object Object],Intranasal palpation reveals movement of the medial canthus.,[object Object]
3D Reconstruction,[object Object],KVS,[object Object]
Nasoorbitalethmoidal(NOE)Fractures,[object Object],KVS,[object Object],Three types of NOE fractures,[object Object],– Type I: Large fragment of medial orbit, medial canthal insertion is intact,[object Object],– Type II: Comminution of bones, fracture line does not extend into area of medial canthal insertion,[object Object],– Type III: Comminution of bones, fracture line extends into area of medial canthal insertion,[object Object]
Management of nasal-orbital ethmoid fractures,[object Object],Examination for determination of the extent of the injury (surgical exploration),[object Object],Nasal bone,[object Object],Orbital and ethmoidal,[object Object],Frontal bone,[object Object],Debridement and closure of open wounds,[object Object],Reduction and stabilization of bone fracture,[object Object],30,[object Object]
Detached canthusTraumatic telecanthus,[object Object],Increase in inter-canthal distance secondary to ,[object Object],canthus displacement or detachment,[object Object],Seen in association to:,[object Object],Nasal bone,[object Object],NEO,[object Object],Le Forts fractures,[object Object],31,[object Object]
Surgical management of detached canthus,[object Object],Transnasal wiring technique (unilateral type),[object Object],Canthopexy ,[object Object],Identification of the ligament,[object Object],Liberation of the periorbital tissue,[object Object],Liberation of the lacrimal pathway,[object Object],Nasal transfixation,[object Object],Contralateral fixation,[object Object],32,[object Object]
Zygomatic bone complex,[object Object],Anatomy,[object Object],Star-shape like with four processes,[object Object],Frontal process,[object Object],Temporal process,[object Object],Buttress,[object Object],Orbital floor (Maxilla and GWSB),[object Object],Temporal fascia ,[object Object],and muscle,[object Object],Masseter muscle,[object Object],33,[object Object]
Zygomatic complex and arch fracture,[object Object],The malar bone represent a strong bone on fragile supports, and it is for this reason that, though the body of the bone is rarely broken, the four processes- frontal, orbital, maxillary and zygomatic are frequent sites of fracture.,[object Object],HD Gillies, TP Kilner and D Stone, 1927,[object Object],34,[object Object],Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.,[object Object]
Signs and symptoms,[object Object],Periorbital ecchymosis and edema,[object Object],Flattening of the malar prominence,[object Object],Flattening over the zygomatic arch,[object Object],Pain and tenderness on palpation,[object Object],Ecchymosis of the maxillary buccal sulcus,[object Object],Deformity at the zygomatic buttress of the maxilla,[object Object],Deformity at the orbital margin,[object Object],35,[object Object]
Trismus,[object Object],Abnormal nerve sensibility,[object Object],Epistaxis,[object Object],Subconjunctivalecchymosis,[object Object],Crepitation from air emphysema,[object Object],Displacement of palpebral fissure (pseudoptosis),[object Object],Unequal pupillary levels,[object Object],Diplopia,[object Object],enophthalmos,[object Object],36,[object Object]
Occipitomental view,[object Object],(Posterioanterior oblique),[object Object],(water’s view),[object Object],37,[object Object]
submentovertex,[object Object],38,[object Object],Recommended for isolated ,[object Object],zygomatic arch fracture,[object Object]
CT scan,[object Object],Coronal sections,[object Object],Axial sections,[object Object],39,[object Object]
Treatment ,[object Object],Timing:,[object Object],As early as possible unless there are ophthalmic, cranial or medical complications,[object Object],Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be postponed but not more than a week,[object Object],40,[object Object],Indications:,[object Object],[object Object]
Restriction of mandibular movement
Restoration of normal contour
Restoration of normal skeletal protection for the eye,[object Object]
Open reduction and fixation,[object Object],Rigid fixation using plate and screws at,[object Object],Frontozygomatic suture,[object Object],Infraorbial rim,[object Object],Inferior buttress of the zygoma,[object Object],42,[object Object],Surgery:,[object Object],[object Object]
Infraorbial approach
Subciliary (blepharoplasty) incision
Mid-lower lid incision
Transconjunctival approach,[object Object]
Isolated Zygomatic Arch Fractures,[object Object],KVS,[object Object]
Maxillary FracturesLeFort I,[object Object],Definition:,[object Object],Horizontal fracture of the maxilla at the level of the nasal fossa.,[object Object],Allows motion of the maxilla while the nasal bridge remains stable.,[object Object]
Maxillary FracturesLeFort I,[object Object],Clinical findings:,[object Object],Facial edema,[object Object],Malocclusion of the teeth,[object Object],Motion of the maxilla while the nasal bridge remains stable,[object Object]
Maxillary FracturesLeFort II,[object Object],Definition:,[object Object],Pyramidal fracture,[object Object],Maxilla,[object Object],Nasal bones ,[object Object],Medial aspect of the orbits,[object Object]
Maxillary FracturesLeFort II,[object Object],Clinical findings:,[object Object],Marked facial edema,[object Object],Nasal flattening,[object Object],Traumatic telecanthus,[object Object],Epistaxis or CSF rhinorrhea ,[object Object],Movement of the upper jaw and the nose. ,[object Object]
Maxillary FracturesLeFort III,[object Object],Definition:,[object Object],Fractures through:,[object Object],Maxilla,[object Object],Zygoma,[object Object],Nasal bones,[object Object],Ethmoid bones,[object Object],Base of the skull								,[object Object]
Maxillary FracturesLeFort III,[object Object],Clinical findings:,[object Object],Dish faced deformity,[object Object],Epistaxis and CSF rhinorrhea,[object Object],Mobility of the maxilla, nasal bones and zygoma,[object Object],Severe airway obstruction,[object Object]
Le Fort fractures seldom confine to exactly to the original classification & combinations of any of the fractures may occur. ,[object Object]
Coronal & Axial CT scan,[object Object]
Treatment,[object Object],closed reduction with inter maxillary fixation (unilateral fractures),[object Object], open reduction. ,[object Object],Open reduction – intra osseous wiring ,[object Object],                              - by using micro or 					miniplates,[object Object]
Internal orbital fractures,[object Object],In conjunction with other facial fractures,[object Object],As isolated type (Blow out fracture),[object Object],54,[object Object]
Anatomy,[object Object],The floor is made of: Maxillary bone and part of zygoma bounded laterally by the inferior orbital fissure and small part of the ethmoid bone,[object Object],55,[object Object]
Clinical and radiographical presentation,[object Object],Subconjunctival ecchymosis,[object Object],Crepitation from air emphysema,[object Object],Displacement of palpebral fissure,[object Object],Unequal pupillary levels,[object Object],Diplopia,[object Object],enophthalmos,[object Object],56,[object Object]
Treatment ,[object Object],Rational for intervention:,[object Object],Small defect with no clinical consequence may not warrant the surgical intervention.,[object Object],Large defect with handicapping symptoms should be operated.,[object Object],57,[object Object]
Method of reconstruction,[object Object],Intra-sinus approach to the orbital floor,[object Object],External approach to the internal orbital floor,[object Object],58,[object Object]
Materials in orbital reconstruction,[object Object],Autologous graft,[object Object],Bone (cranial, rib, iliac) ,[object Object],Cartilage,[object Object],Allogenic materials,[object Object],Lyophilized dura,[object Object],Alloplastic materials,[object Object],Siliastic and proplast implants,[object Object],Teflon,[object Object],hydroxyapatite,[object Object],Titanium mish,[object Object],59,[object Object]
Mandible FracturesPathophysiology,[object Object],Mandibular fractures are the third most common facial fracture.,[object Object],Assaults and falls on the chin account for most of the injuries.,[object Object],Multiple fractures are seen in greater then 50%.,[object Object],Associated  C-spine injuries – 0.2-6%.,[object Object]
KVS,[object Object]
Epidemiology,[object Object],Sites of weakness,[object Object],Third molar (esp. impacted),[object Object],Socket of canine tooth,[object Object],Condylar neck,[object Object]
Haug et al,[object Object]
Favorable vs. Unfavorable,[object Object],Masseter, Medial and Lateral Pterygoid, and Temporalis tend to draw fractures medial and superior,[object Object],Almost all fractures of angle unfavorable,[object Object]
Maxillofacial injuries
Physical Exam,[object Object],Complete Head and Neck exam,[object Object],Palpable step off,[object Object],Tenderness to palpation,[object Object],Malocclusion,[object Object],Trismus (35 mm or less),[object Object],Sublingual hematoma,[object Object],Altered sensation of V3,[object Object],Crepitus,[object Object]
Mandible FracturesClinical findings,[object Object],Mandibular pain.,[object Object],Malocclusion of the teeth,[object Object],Separation of teeth with intraoral bleeding,[object Object],Inability to fully open mouth.,[object Object],Preauricular pain with biting. ,[object Object],.,[object Object]
Physical Exam,[object Object],Unilateral fractures of Condyle,[object Object],Decreased translational movement, functional height of condyle,[object Object],Deviation of chin away from fracture, open bite opposite side of fracture,[object Object],Bilateral fractures of condyle,[object Object],	- Anterior open bite,[object Object]
Maxillofacial injuries
Radiographic Evaluation,[object Object],Panorex (OPG),[object Object],X ray skull Reverse towns view.,[object Object],X Ray mandible PA View, Lateral oblique views,[object Object],TMJ views,[object Object]
Radiographic Evaluation,[object Object],CT scan,[object Object],Not as diagnostic as plain films for nondisplaced fractures of mandible.,[object Object],Most useful for coronoid and condylar fractures, associated midface fractures,[object Object],KVS,[object Object]
Closed Reduction,[object Object],Favorable, non-displaced fractures,[object Object],Grossly comminuted fractures when adequate stabilization unlikely,[object Object],Severely atrophic edentulous mandible,[object Object],Children with developing dentition,[object Object]
Open Reduction,[object Object],Displaced unfavorable fractures,[object Object],Mandible fractures with associated midface fractures,[object Object],When MMF contraindicated or not possible,[object Object],Patient comfort,[object Object],Facilitate return to work,[object Object]
Open Reduction,[object Object],Associated condylar fracture,[object Object],Associated Midface fractures,[object Object],Psychiatric illness,[object Object],GI disorders involving severe N/V,[object Object],Severe malnutrition,[object Object],To avoid tracheostomy in patients who need postoperative intubation,[object Object]
Open Reduction,[object Object],Contraindications,[object Object],General Anesthetic risk too high,[object Object],Severe comminution and stabilization not possible,[object Object],No soft tissue to cover fracture site,[object Object],Bone at fracture site diffusely infected (controversial),[object Object]
Closed Reduction,[object Object],Length of MMF,[object Object],Fracture at angle of mandible for adults : 4 wks,[object Object],Add 2 wks more for symphysis fracture,[object Object],Add 2 wks for geriatric patients (edentulous),[object Object],Less 1 wk for peadiatricmandibular fractures.,[object Object],Less 1 wk for condylar fractures.,[object Object]
Maxillofacial injuries
Maxillofacial injuries
Open ReductionTechniques,[object Object],Rigid fixation ,[object Object],Compression plates (DCP),[object Object], Lag screws,[object Object],Semirigid fixation,[object Object],Miniplates,[object Object],Transosseous wiring,[object Object],External fixators,[object Object]
Rigid Fixation,[object Object],Compression plates,[object Object],Rigid fixation,[object Object],Allow primary bone healing,[object Object],Difficult to bend,[object Object],Operator dependent,[object Object],No need for MMF,[object Object]
Maxillofacial injuries
Open Reduction,[object Object],Lag Screws,[object Object],Rigid fixation (Compression),[object Object],Good for anterior mandible fractures, Oblique body fractures, mandible angle fractures,[object Object],Cheap,[object Object],Technically difficult,[object Object],Injury to inferior alveolar neurovascular bundle,[object Object]
Lag Screw Technique,[object Object]
Lag Screw Technique,[object Object]
Semi Rigid Fixation,[object Object],Miniplates,[object Object],Semi-rigid fixation,[object Object],Mono cortical screws,[object Object],Uses tension band principle,[object Object],Allows primary and secondary bone healing,[object Object],Easily bendable,[object Object],More forgiving,[object Object],Short period MMF Recommended,[object Object]
Maxillofacial injuries
Champey’sminiplateosteosynthesis,[object Object],Areas of tension and compression,[object Object],2 mm plates ,[object Object],Monocortical screws.,[object Object],Placed in favourable positions on mandible.,[object Object],Micromovements possible favourable to healing.,[object Object],Technically not highly demanding.,[object Object],Plate removal is not routinely required.,[object Object],KVS,[object Object]
External Fixation,[object Object],Alternative form of rigid fixation,[object Object],Grossly comminuted fractures, contaminated fractures, non-union,[object Object],Often used when all else fails,[object Object]
Condylar and Subcondylar ,[object Object],Lindhal and Hollender,[object Object],Closed reduction in children, teens, adults,[object Object],Intracapsular fractures,[object Object],Higher incidence of postoperative sequelae in adults,[object Object],Children and Teens with less sequelae, more remodeling ,[object Object]
Condylar and Subcondylar,[object Object],ORIF, Absolute indications,[object Object],Displacement into middle cranial fossa,[object Object],Inability to achieve occlusion with closed reduction,[object Object],Foreign body in joint space,[object Object]
Condylar and Subcondylar,[object Object],Relative indications,[object Object],Bilateral condylar fractures to preserve vertical height,[object Object],Associated injuries that dictate earlier function,[object Object],Soft tissue swelling causing airway compromise with MMF,[object Object],Intracapsular fracture on opposite side where early mobilization important,[object Object]
Maxillofacial injuries
Panfacial fractures,[object Object],Expose all fracture sites,[object Object],Reconstruct the AP projection of face, start from stable post area (temporal bone, proximal arch,[object Object],Reconstruct the width of the face across zygomatic arches (frontozygomatic suture),[object Object],Recreate NOE area.,[object Object],Restore height (fix ramus fractures),[object Object],Restore occlusion.,[object Object],Repair the fractures in maxilla and mandible closer to teeth bearing areas,[object Object],KVS,[object Object]

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Maxillofacial injuries