Oral and Maxillofacial area is a crucial area for respiration, digestive, and esthetic functions. When traumatized, a backup of knowledge and skills is required to restore pleasing look and function. This ppt details how to optimize the emergency and late better outcomes of patients with oral and maxillofacial trauma.

1. Emergency management of oral
and maxillofacial trauma
including prophylactic
antibiotherapy.
Dr. NDAYISHIMIYE Samuel
Dental Surgeon.

2. OUTLINES
• Introduction
• Etiology of oral and maxillofacial trauma
• Assessment of patient with OMF trauma
• Soft tissues trauma
• Mandible fracture and emergency management
• Midface fractures and emergency management
• Dental trauma
• Complications of oral and maxillofacial trauma
• Prophylactic ntibiotherrapy
• References

3. Introduction
• What is tissue trauma?
• Is the damage of tissues by physical , thermal, chemicals agents.
• When do we say maxillofacial trauma is an emergency?
• Airway compromise
• Brain injury
• C-spine injury
• Avulsion of tissues.

4. Introduction contd..
• Oral and maxillofacial region is crucial area that serves in Airway , esthetic,
mastication and speech.
• Facial injuries deserve special attention because of their complications and
esthetic significance.
• Facial trauma are life threatening because of airway compromise, bleeding,
and infections.
• injury causes include moto-vehicle accidents ,falls, sports, fights, and
domestic violence.
• Facial trauma is among the common causes of maxillofacial emergencies
• May be associated with other life threatening injury like C-spine, brain
injury and extremities..

5. Etiology of OMF trauma
• Most of cause of the injuries include moto-vehicle , accidents ,falls, sports,
fights, and domestic violence.
• Motorcycle(24.7%)
• Moto-car(20.9%)
• Fall accident(17.6%)
• Bicycle(14.3%)
• Assault(7.7%)
• Domestic violence(7.1%)
• Sports accident(5.5%)
• Others(2.2%)

6. Classification of oral and maxillofacial injuries
Soft tissues trauma
Abrasions
Contusions
Echymosis
Lacerations
avulsion
Hard tissues trauma
fractures
Upper face fractures
Mid-face fractures
Lower face fractures
Displacement
dislocations
Teeth and dento-alveolar
injuries.

7. Emergency management of OMF Trauma
• emergency management of oral and maxillofacial trauma patient requires
advanced trauma life support(ATLS)
• Triage
• Primary survey
• Resuscitation
• Adjunct to primary survey
• ABCDE
• Secondary survey
• Adjunct to secondary survey
• Definitive care

8. Emergency management contd,……
• Secondary survey(AMPLE)
Head to toe examination
Allergy
Medications
Past illness/pregnancy
Last meal
Exposure/event.
• Triage: who is more critical?
based on ABC priorities.
Primary survey:
Airway and C spine protection.
Breathing and Ventilation
Circulation with hemorrhage
control
Disability (neurological status GCS,
sensation, movement and motor
power)
Exposure/environmental control.

9. Emergency management contd,……
• Airway
• Call the patient if not responding consider
the Airway to be compromised.
• Inspect for foreign body, facial,
mandibular, laryngeal or tracheal fracture.
• Suction of all clots, and secretions.
• Jaw-thrust or chin-lift maneuver to open
airways.
• Oro-tracheal intubation for unconscious
without gag reflex.
• Prevent excessive movement of C spine
• Might have C spine injury.
• C collar placement.
• Breathing and ventilation
• Ensure chest expansion
• Pulse oximeter to see hemoglobin
saturation.
• Look for signs of tension pneumothorax,
massive hemothorax,open
pneumothorax, tracheal or laryngeal
injuries.
• Supplemental oxygen
• tension pneumothorax affect both
respiration and circulation
• Needle decompression

10. Emergency management contd,……
• Areas of tension pneumothorax needle decompression, jaw thrust
and chin lift for airway and breathing management

11. Emergency management contd,……
• Circulation
• Assess cardiac output and bleeding.
• Quick identification and control of
hemorrhage is crucial.
• If tension pneumothorax is excluded,
hypotension is the cause of chock until
proven otherwise.
• 3 elements of CO assessment
• Level of consciousness: stable/altered
• Skin perfusion : pink face, extremities/gray
facial skin/pale and cold extremities.
• Pulse: rapid thread, absent central pulse point
for immediate need of resuscitation.
• External bleeding has to be controlled by
direct pressure on wound. Tourniquet may be
applied if direct pressure on extremity is not
effective.
• Major areas of internal bleeding are chest,
abdomen , retroperitoneum, pelvis and long
bones.
• Use of imaging helps. Chest x-ray, pelvic x-ray,
FAST(focused assessment with sonography for
trauma)
• Replacement of intravascular volume.

12. Emergency management contd,……
• Disability
• GCS
• Pupillary size and reaction
• Determine spinal cord injury level
• Decreased consciousness may indicate
Brain hypoxia,
 hypo-perfusion ,
 hypoglycemia,
direct cerebral injury
• Adequate oxygenation and perfusion to prevent secondary brain injury

13. Emergency management contd,……
• Exposure and environmental control
removal of garments for thorough examination
Cover with blanket to prevent hypothermia
Warm IV fluids to the body temperature.

14. Emergency management contd,……
• Secondary survey(AMPLE)
Head to toe examination
Allergy
Medications
Past illness/pregnancy
Last meal
Exposure/event.

15. Assessment of patient with OMF trauma
• History of mechanism of injury is the key(from the patient or
whiteness who were at the scene if patient is unconscious)
• Examination should be quick and proper.
• Begin with overall inspection noting any facial
asymmetries,wound,hemorrhage,serous discharge and ecchymosis.
• Neurological examination of 12 CN.
• Assessment of sensory nerves(ophthalmic , maxillary and
mandibular.)

16. Assessment cont’d,..
• Soft tissues injuries
• Lips(through band through lacerations)
• Facial symmetry
• Occlusion : disturbed in maxillofacial fractures.
• Peri-orbital and conjuctival ecchymosis,
• Palatal and sublingual hematoma
• CSF leakage(rhinorrhea, otorrhea)
• Tenderness in facial area
• Step deformity
• Respiration pattern
• C spine dermatomes.

17. Soft tissues injuries and their management
• Hematoma:
 is localized collection of the blood in
subcutaneous, intramuscularly or submucosal.
 Most are reabsorbed
 Persistent ones may require incision and drainage.
 Antibiotic cover for prevention of hematoma
infection.
• Abrasions:
 friction between an object and soft tissue surface.
 Epidermis involved but sometimes deeper layers’
 Painful.
 Mngt: clean and irrigate with saline
 Foreign body removal.
 Topical antibiotics
• Contusion:
 due to blow or fall against hard and brunt object.
 Blood extravasation from subcutaneous or
submucosa causing bruises.
 Look for the osseous trauma!!!
 Mgt: ice pack.

18. Soft tissues injuries and their management
• Lacerated and avulsive wound
Most frequently accoutered type of wound.
Vehicle accidents, Low velocity missiles or
bomb splinters.
Contused tissues , muscles are also lacerated
and devitalized.
May be associated with Injury to underlying
vessels, nerves or bone.
Contaminated with dust, sand, mud, bone
splinters,…
Lacerations and avulsive wounds best
sutured in first 6hrs. Not latter than 24 hrs
Suturing layer by layer(Skin,muscle,fascia.
And mucosa)
Debridement and irrigation
Open dressing with tetracycline 1%
Prophylactic antibiotics( broad spectrum
antibiotics: Amoxicillin,
Augmentin,Ceftriaxone, not cloxacillin!!! Add
metronidazole if tissues are infected :
Clindamycin of allergic to penicillins and
Cepharosporins)
Oral mouthwashes(Rhexedine,
Chlorhexidine,hydrogen peroxide,…)
Intra-oral wounds never be clean!!!

19. Soft tissues injuries and their management
• Penetrating and punctured
wound
Caused by pin pointed objects
like knife , bullet, bomb splinters.
Careful clinical examination
Other investigations like CT scan
are required.
• Gun shot injuries
They are penetrating injuries
but classified separately due to
their complicated management.
They are penetrating ,
perforating and avulsive.

20. Hard tissue trauma and their management
• Midface Fractures
• Lefort I
 Detached maxillary alveolar process
 Management:MMF,ORIF
• Lefort II(Pyramidal)
 Detached Maxilla(mobile maxilla)
 Management:MMF,ORIF
• Lefort III(transverse, cranio-facial disjunction)
 The face is detached from the cranial cavity
Airway compromises
Assending meningitis
Cavernous thrombosis
Management:ORIF

21. Hard tissue trauma and their management
• Features: facial echymoses, facial
tenderness,conjunctiva echymoses, disturbed
occular movements, Step deformities, CSF
Rhinorrhea and Otorhea, Malocclusion, anterior
open bites.palatal echymoses
• Usually associated with Head injury( traumatic
brain injury),C-spine injury or Chest And
extremities fractures .
• Downward and posterior displacement of
detached segment.
• Emergency Airway compromises , highly bleed!!!
• ATLS
• Antibiotics+Painkillers+ mouthwash
• Investigation: FBC,renal function,liver anzymes, CT-
scan of head and neck without contrast.

22. Hard tissue trauma and their management
• Mandibular fractures
 Features: swelling on site, trissmuss, sublingual hematoma,
Malocclusion (open bites),step deformity upon palpation.
 Investigation:OPG,PA of Skull,Lateral skull
 Classification: symphysial,parasymhysial,angle, and ramus
and condyle of the mandible.
 Bilateral parasymphysial or body of mandible fractures have
downward and posterior displacement due to suprahyoid
muscles that cause Airway compromise
 Open or closed, displaced or non displaced.
 Treatment: Airway patency!!!!
 IM Dexamethasone
 Antibiotics+ pain killers and mouthwash
 Advise patients to lye in rescue position.
 Management is close with(MMF) or is for ORIF

23. Hard tissue trauma and their management
• Dental trauma and management
• Avulsion: do not throw avulsed tooth!! Keep it in
NS,Milk wait for a dentist to do re-implantation.
Emergency treatment:Pain management,
prophylaxis antibiotics+ mouthwash. Re-
implantation and fixation.
• Subluxation: Teeth are mobile, not in their
anatomical position, Emergency treatment:Pain
management,Oral hygiene And prophylaxis+ soft
diet then dentist will split the teeth
• Crown fractures: Oral hygiene,cover with Calcium
hydroxide.
• Dento-alveolar fractures: segment of teeth in same
region displaced from their location, mobile,
painful.Emergency treatment: pain management,
Prophylactic antibiotics + mouthwash. MMF,
interdental wiring of composite splitting.

24. Complications of oral and maxillofacial trauma
• Immediate and early: Airway obstruction, Bleeding, nerve injuries,
Pain, swelling, malocclusion, Shock, death.
• Intermediate: Trismus , Infections, Sepsis , Infective endocarditis,
meningitis ,Cavernous thrombosis, Fascial space infections, death.
• Late: Osteomyelitis, facial deformity, Malunion,malocclusions, scars,
PTSD(post-traumatic stress disorder , TMJ ankylosis.

25. PROPHYLACTIC ANTIBIOTHERRAPY
• MODE OF ACTION
• Cell wall active agents
• Protein synthesis inhibitors
• DNA synthesis inhibitors

26. PENICILLINS
Narrow spectrum
• Natural penicillins
• Pen G and Pen V are effective on Gram + cocci and Bacilli,
few gram- cocci and spirochetes like Treponema pallidum
but Fail on gram – Bacilli
• Used in prophylactis of rheumatic fever in children with
pharyngitis
• Mixed aerobic and anaerobic infection
• Very very narrow spectrum
• Called also Antistaphylococcal penicillins
• Methicillin:interstitial nephritis
• Nafcillin:nephrititis,neutropenia
• Cloxacillin
• Dicloxacillin
• They are active only on staphylococcus
Wide spectrum
• Ampicillin
• Amoxicillin
• Active on both Gram +and gram – bacteria
• Enterococci.
• Hemophillus influenza
• E coli
• Listeria monocytogenus
• Proteus
• Salmonera
• Clavulanic acid
• Sulbactam
• Tazobactam

27. PENICILLINS
Extended spectrum
• Augmentin(amoxicillin+clavulani
c acid)
• Unasyn(ampicillin+Sulbactam)
Extended broad spectrum
• Antipseudomona penicillins
• Piperacillin
• Carbenicillin
• Ticarcillin
• Zosyn is Piperacillin+ Tazobactam
• Timentin is Ticarcillin+clavulaic
acid

28. Most Prophylactic combinations used in OMFS
• Amoxicillin 30-50mg/kg TID
• Cloxacillin 30-50mg/kg TID
• Metronidazole 15mg/kg TID
• Ceftriaxone 30mg/kg BID
• Gentamycin 4-7mg/kg OD maximum 160mg
• Augmentin 625mg
• Combination of amoxicillin + metronidazole
• Combination of ceftriaxone + metronidazole
• Combination of ceftriaxone + metronidazole + gentamycin
• Mouth washes
• Rexedine, betadine, chlorhexidine
• Hydrogen peroxide, listerine,..
• Ointments
• Tetracycline 3%

29. ANTIBIOTICS
• PENICILLINS
• CLINDAMYCINE
• VANCOMYCIN
• METRONIDAZOLE
• MACROLIDES
• TETRACYCLINES
• CEPHALOSPORINS
• ANTIFUNGAL

30. Thank you

31. References
• American College Of Surgeons, Committee On Trauma.(2018) ATLS
Manual. The 10th Ed.
• james.R. (2014)'Contemporary oral and maxillofacial surgery 7th
edition’.
• David et al.(2003)Textbook of general and oral surgery. edn.
Philadelphia,PA: Chulchil Livingstone/Elsevier.
• Mohammad et al. (2013). ‘Maxillofacial reconstruction of ballistic
injuries’. A textbook of advanced oral and maxillofacial surgery. P
532-557.