Maxillofacial injuries

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Maxillofacial injuries

  1. 1. Maxillo facial injuriesDepartment of dentistryTata Main HospitalDr K V Sebastian<br />KVS<br />
  2. 2. KVS<br />Maxillofacial injuries<br />
  3. 3. Learning Objectives<br />To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head & spinal injuries.<br />Method of examining facial injuries.<br />Diagnosis & principles of management of facial injuries<br />KVS<br />3<br />
  4. 4. Anatomy<br />KVS<br />
  5. 5. Anatomy<br />KVS<br />
  6. 6. Causes<br />Road traffic accidents<br />Intentional violence<br />Sporting activities<br />KVS<br />
  7. 7. Pathophysiology<br />High Impact:<br />Supraorbital rim – 200 G<br />Symphysis of the Mandible –100 G<br />Frontal – 100 G<br />Angle of the mandible – 70 G<br />Low Impact:<br />Zygoma – 50 G<br />Nasal bone – 30 G<br />KVS<br />
  8. 8. Severity<br />@60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.<br />20-50% concurrent brain injury.<br />1-4% cervical spine injuries.<br />Blindness occurs in 0.5-3% <br />KVS<br />
  9. 9. Assessment <br />Based on<br />Targeting care: Glasgow Coma Scale (GCS)<br />Predicting outcome: Abbreviated Injury Scale (AIS) and Injury Severity Score(ISS)<br />Assessing critically injured patients: APACHE II<br />KVS<br />
  10. 10. Initial hospital care<br />Triage the causalities(sorting for prioritization)<br />A: airway with cervical spine control<br />B: breathing and ventilation<br />C: circulation and hemorrhage control<br />D: disability due to neurologic deficit<br />E: exposure and environment control<br />KVS<br />
  11. 11. Clinical effects<br />Injuries to facial skeleton -> <br /> Immediate airway obstruction<br /> delayed airway obstruction<br />KVS<br />
  12. 12. Immediate airway obstruction<br /> inhalation of tooth fragments<br /> accumulation of blood & secretions <br /> loss of control of tongue in unconscious/ semiconscious pt. -><br />KVS<br />
  13. 13. Emergency ManagementAirway Control<br />Control airway:<br />Chin lift.<br />Jaw thrust.<br />Oropharyngeal suctioning.<br />Manually move the tongue forward.<br />Maintain cervical immobilization<br />KVS<br />
  14. 14. Emergency ManagementIntubation Considerations<br />Avoid nasotracheal intubation:<br />Nasocranial intubation<br />Nasal hemorrhage<br />Avoid Rapid Sequence Intubation:<br />Failure to intubate or ventilate.<br />Consider awake intubation.<br />Sedate with benzodiazepines. <br />KVS<br />
  15. 15. Emergency ManagementIntubation Considerations<br />Consider fiberoptic intubation if available. <br />Alternatives include percutaneous transtracheal ventilation and retrograde intubation.<br />Be prepared for cricothyroidotomy.<br />KVS<br />
  16. 16. Emergency ManagementHemorrhage Control<br />Maxillofacial bleeding:<br />Direct pressure.<br />Avoid blind clamping in wounds.<br />Nasal bleeding:<br />Direct pressure.<br />Anterior and posterior packing.<br />Pharyngeal bleeding:<br />Packing of the pharynx around ET tube.<br />KVS<br />
  17. 17. History<br />Obtain a history from the patient, witnesses and or EMS<br />Specific Questions:<br />Was there LOC? If so, how long?<br />How is your vision?<br />Hearing problems?<br />KVS<br />
  18. 18. History<br />Specific Questions:<br />Is there pain with eye movement?<br />Are there areas of numbness or tingling on your face?<br />Is the patient able to bite down without any pain?<br />Is there pain with moving the jaw?<br />KVS<br />
  19. 19. Clinical examination<br />ATLS standard approach<br />Inspection<br />Palpation<br />Visual examination<br />Eye movement<br />Diplopia<br />Pupil reaction<br />19<br />
  20. 20. Physical Examination<br />Inspection of the face for asymmetry.<br />Inspect open wounds for foreign bodies.<br />Palpate the entire face.<br />Supraorbital and Infraorbital rim<br />Zygomatic-frontal suture<br />Zygomatic arches<br />KVS<br />
  21. 21. Physical Examination<br />Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.<br />Inspect nasal septum for septal hematoma, CSF or blood.<br />Palpate nose for crepitus, deformity and subcutaneous air.<br />Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone. <br />KVS<br />
  22. 22. Physical Examination<br />Check facial stability.<br />Inspect the teeth for malocclusions, bleeding and step-off.<br /> Intraoral examination: <br />Manipulation of each tooth.<br />Check for lacerations.<br />Stress the mandible.<br />Tongue blade test.<br />Palpate the mandible for <br />tenderness, swelling and step-off.<br />KVS<br />
  23. 23. Fractures of Facial Skeleton<br />Upper third – above the eyebrows – involves frontal sinuses & supraorbital ridges<br />Middle third – above the mouth<br /> Le Fort I , II , II<br />Lower third -- Mandible<br />
  24. 24. Imaging of Facial Trauma<br />Frontal Sinus/ Bone FracturesDiagnosis<br />Radiographs:<br />Facial views should include <br />Waters, Caldwell and lateral projections.<br />Caldwell view best evaluates <br />the anterior wall fractures.<br />KVS<br />
  25. 25. Frontal Sinus/ Bone FracturesDiagnosis<br />CT Head with bone windows:<br />Frontal sinus fractures. <br />Orbital rim and nasoethmoidal fractures.<br />R/O brain injuries or intracranial bleeds.<br />
  26. 26. Naso-Ethmoidal-Orbital Fracture<br />Fractures that extend into the nose through the ethmoid bones.<br />Associated with lacrimal disruption and dural tears.<br />Suspect if there is trauma to the nose or medial orbit.<br />Patients complain of pain on eye movement.<br />
  27. 27. Naso-Ethmoidal-Orbital Fracture<br />Clinical findings:<br />Flattened nasal bridge or a saddle-shaped deformity of the nose.<br />Widening of the nasal bridge (telecanthus)<br />CSF rhinorrhea or epistaxis.<br />Tenderness, crepitus, and mobility of the nasal complex.<br />Intranasal palpation reveals movement of the medial canthus.<br />
  28. 28. 3D Reconstruction<br />KVS<br />
  29. 29. Nasoorbitalethmoidal(NOE)Fractures<br />KVS<br />Three types of NOE fractures<br />– Type I: Large fragment of medial orbit, medial canthal insertion is intact<br />– Type II: Comminution of bones, fracture line does not extend into area of medial canthal insertion<br />– Type III: Comminution of bones, fracture line extends into area of medial canthal insertion<br />
  30. 30. Management of nasal-orbital ethmoid fractures<br />Examination for determination of the extent of the injury (surgical exploration)<br />Nasal bone<br />Orbital and ethmoidal<br />Frontal bone<br />Debridement and closure of open wounds<br />Reduction and stabilization of bone fracture<br />30<br />
  31. 31. Detached canthusTraumatic telecanthus<br />Increase in inter-canthal distance secondary to <br />canthus displacement or detachment<br />Seen in association to:<br />Nasal bone<br />NEO<br />Le Forts fractures<br />31<br />
  32. 32. Surgical management of detached canthus<br />Transnasal wiring technique (unilateral type)<br />Canthopexy <br />Identification of the ligament<br />Liberation of the periorbital tissue<br />Liberation of the lacrimal pathway<br />Nasal transfixation<br />Contralateral fixation<br />32<br />
  33. 33. Zygomatic bone complex<br />Anatomy<br />Star-shape like with four processes<br />Frontal process<br />Temporal process<br />Buttress<br />Orbital floor (Maxilla and GWSB)<br />Temporal fascia <br />and muscle<br />Masseter muscle<br />33<br />
  34. 34. Zygomatic complex and arch fracture<br />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.<br />HD Gillies, TP Kilner and D Stone, 1927<br />34<br />Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.<br />
  35. 35. Signs and symptoms<br />Periorbital ecchymosis and edema<br />Flattening of the malar prominence<br />Flattening over the zygomatic arch<br />Pain and tenderness on palpation<br />Ecchymosis of the maxillary buccal sulcus<br />Deformity at the zygomatic buttress of the maxilla<br />Deformity at the orbital margin<br />35<br />
  36. 36. Trismus<br />Abnormal nerve sensibility<br />Epistaxis<br />Subconjunctivalecchymosis<br />Crepitation from air emphysema<br />Displacement of palpebral fissure (pseudoptosis)<br />Unequal pupillary levels<br />Diplopia<br />enophthalmos<br />36<br />
  37. 37. Occipitomental view<br />(Posterioanterior oblique)<br />(water’s view)<br />37<br />
  38. 38. submentovertex<br />38<br />Recommended for isolated <br />zygomatic arch fracture<br />
  39. 39. CT scan<br />Coronal sections<br />Axial sections<br />39<br />
  40. 40. Treatment <br />Timing:<br />As early as possible unless there are ophthalmic, cranial or medical complications<br />Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be postponed but not more than a week<br />40<br />Indications:<br /><ul><li>Diplopia
  41. 41. Restriction of mandibular movement
  42. 42. Restoration of normal contour
  43. 43. Restoration of normal skeletal protection for the eye</li></li></ul><li>Methods of reduction<br />Temporal approach (Gillies et al 1927)<br />41<br /><ul><li>Buccalsulcus approach (Keen 1909)</li></ul>Suitable for isolated <br />zygomatic fracture with <br />good stability afterwards<br />
  44. 44. Open reduction and fixation<br />Rigid fixation using plate and screws at<br />Frontozygomatic suture<br />Infraorbial rim<br />Inferior buttress of the zygoma<br />42<br />Surgery:<br /><ul><li>Lateral eyebrow incision
  45. 45. Infraorbial approach
  46. 46. Subciliary (blepharoplasty) incision
  47. 47. Mid-lower lid incision
  48. 48. Transconjunctival approach</li></li></ul><li>43<br />Points of fixation:<br />Infraorbital rim and buttress<br />Lateral orbital rim<br />Buttress of zygoma<br />
  49. 49. Isolated Zygomatic Arch Fractures<br />KVS<br />
  50. 50. Maxillary FracturesLeFort I<br />Definition:<br />Horizontal fracture of the maxilla at the level of the nasal fossa.<br />Allows motion of the maxilla while the nasal bridge remains stable.<br />
  51. 51. Maxillary FracturesLeFort I<br />Clinical findings:<br />Facial edema<br />Malocclusion of the teeth<br />Motion of the maxilla while the nasal bridge remains stable<br />
  52. 52. Maxillary FracturesLeFort II<br />Definition:<br />Pyramidal fracture<br />Maxilla<br />Nasal bones <br />Medial aspect of the orbits<br />
  53. 53. Maxillary FracturesLeFort II<br />Clinical findings:<br />Marked facial edema<br />Nasal flattening<br />Traumatic telecanthus<br />Epistaxis or CSF rhinorrhea <br />Movement of the upper jaw and the nose. <br />
  54. 54. Maxillary FracturesLeFort III<br />Definition:<br />Fractures through:<br />Maxilla<br />Zygoma<br />Nasal bones<br />Ethmoid bones<br />Base of the skull <br />
  55. 55. Maxillary FracturesLeFort III<br />Clinical findings:<br />Dish faced deformity<br />Epistaxis and CSF rhinorrhea<br />Mobility of the maxilla, nasal bones and zygoma<br />Severe airway obstruction<br />
  56. 56. Le Fort fractures seldom confine to exactly to the original classification & combinations of any of the fractures may occur. <br />
  57. 57. Coronal & Axial CT scan<br />
  58. 58. Treatment<br />closed reduction with inter maxillary fixation (unilateral fractures)<br /> open reduction. <br />Open reduction – intra osseous wiring <br /> - by using micro or miniplates<br />
  59. 59. Internal orbital fractures<br />In conjunction with other facial fractures<br />As isolated type (Blow out fracture)<br />54<br />
  60. 60. Anatomy<br />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<br />55<br />
  61. 61. Clinical and radiographical presentation<br />Subconjunctival ecchymosis<br />Crepitation from air emphysema<br />Displacement of palpebral fissure<br />Unequal pupillary levels<br />Diplopia<br />enophthalmos<br />56<br />
  62. 62. Treatment <br />Rational for intervention:<br />Small defect with no clinical consequence may not warrant the surgical intervention.<br />Large defect with handicapping symptoms should be operated.<br />57<br />
  63. 63. Method of reconstruction<br />Intra-sinus approach to the orbital floor<br />External approach to the internal orbital floor<br />58<br />
  64. 64. Materials in orbital reconstruction<br />Autologous graft<br />Bone (cranial, rib, iliac) <br />Cartilage<br />Allogenic materials<br />Lyophilized dura<br />Alloplastic materials<br />Siliastic and proplast implants<br />Teflon<br />hydroxyapatite<br />Titanium mish<br />59<br />
  65. 65. Mandible FracturesPathophysiology<br />Mandibular fractures are the third most common facial fracture.<br />Assaults and falls on the chin account for most of the injuries.<br />Multiple fractures are seen in greater then 50%.<br />Associated C-spine injuries – 0.2-6%.<br />
  66. 66. KVS<br />
  67. 67. Epidemiology<br />Sites of weakness<br />Third molar (esp. impacted)<br />Socket of canine tooth<br />Condylar neck<br />
  68. 68. Haug et al<br />
  69. 69. Favorable vs. Unfavorable<br />Masseter, Medial and Lateral Pterygoid, and Temporalis tend to draw fractures medial and superior<br />Almost all fractures of angle unfavorable<br />
  70. 70.
  71. 71. Physical Exam<br />Complete Head and Neck exam<br />Palpable step off<br />Tenderness to palpation<br />Malocclusion<br />Trismus (35 mm or less)<br />Sublingual hematoma<br />Altered sensation of V3<br />Crepitus<br />
  72. 72. Mandible FracturesClinical findings<br />Mandibular pain.<br />Malocclusion of the teeth<br />Separation of teeth with intraoral bleeding<br />Inability to fully open mouth.<br />Preauricular pain with biting. <br />.<br />
  73. 73. Physical Exam<br />Unilateral fractures of Condyle<br />Decreased translational movement, functional height of condyle<br />Deviation of chin away from fracture, open bite opposite side of fracture<br />Bilateral fractures of condyle<br /> - Anterior open bite<br />
  74. 74.
  75. 75. Radiographic Evaluation<br />Panorex (OPG)<br />X ray skull Reverse towns view.<br />X Ray mandible PA View, Lateral oblique views<br />TMJ views<br />
  76. 76. Radiographic Evaluation<br />CT scan<br />Not as diagnostic as plain films for nondisplaced fractures of mandible.<br />Most useful for coronoid and condylar fractures, associated midface fractures<br />KVS<br />
  77. 77. Closed Reduction<br />Favorable, non-displaced fractures<br />Grossly comminuted fractures when adequate stabilization unlikely<br />Severely atrophic edentulous mandible<br />Children with developing dentition<br />
  78. 78. Open Reduction<br />Displaced unfavorable fractures<br />Mandible fractures with associated midface fractures<br />When MMF contraindicated or not possible<br />Patient comfort<br />Facilitate return to work<br />
  79. 79. Open Reduction<br />Associated condylar fracture<br />Associated Midface fractures<br />Psychiatric illness<br />GI disorders involving severe N/V<br />Severe malnutrition<br />To avoid tracheostomy in patients who need postoperative intubation<br />
  80. 80. Open Reduction<br />Contraindications<br />General Anesthetic risk too high<br />Severe comminution and stabilization not possible<br />No soft tissue to cover fracture site<br />Bone at fracture site diffusely infected (controversial)<br />
  81. 81. Closed Reduction<br />Length of MMF<br />Fracture at angle of mandible for adults : 4 wks<br />Add 2 wks more for symphysis fracture<br />Add 2 wks for geriatric patients (edentulous)<br />Less 1 wk for peadiatricmandibular fractures.<br />Less 1 wk for condylar fractures.<br />
  82. 82.
  83. 83.
  84. 84. Open ReductionTechniques<br />Rigid fixation <br />Compression plates (DCP)<br /> Lag screws<br />Semirigid fixation<br />Miniplates<br />Transosseous wiring<br />External fixators<br />
  85. 85. Rigid Fixation<br />Compression plates<br />Rigid fixation<br />Allow primary bone healing<br />Difficult to bend<br />Operator dependent<br />No need for MMF<br />
  86. 86.
  87. 87. Open Reduction<br />Lag Screws<br />Rigid fixation (Compression)<br />Good for anterior mandible fractures, Oblique body fractures, mandible angle fractures<br />Cheap<br />Technically difficult<br />Injury to inferior alveolar neurovascular bundle<br />
  88. 88. Lag Screw Technique<br />
  89. 89. Lag Screw Technique<br />
  90. 90. Semi Rigid Fixation<br />Miniplates<br />Semi-rigid fixation<br />Mono cortical screws<br />Uses tension band principle<br />Allows primary and secondary bone healing<br />Easily bendable<br />More forgiving<br />Short period MMF Recommended<br />
  91. 91.
  92. 92. Champey’sminiplateosteosynthesis<br />Areas of tension and compression<br />2 mm plates <br />Monocortical screws.<br />Placed in favourable positions on mandible.<br />Micromovements possible favourable to healing.<br />Technically not highly demanding.<br />Plate removal is not routinely required.<br />KVS<br />
  93. 93. External Fixation<br />Alternative form of rigid fixation<br />Grossly comminuted fractures, contaminated fractures, non-union<br />Often used when all else fails<br />
  94. 94. Condylar and Subcondylar <br />Lindhal and Hollender<br />Closed reduction in children, teens, adults<br />Intracapsular fractures<br />Higher incidence of postoperative sequelae in adults<br />Children and Teens with less sequelae, more remodeling <br />
  95. 95. Condylar and Subcondylar<br />ORIF, Absolute indications<br />Displacement into middle cranial fossa<br />Inability to achieve occlusion with closed reduction<br />Foreign body in joint space<br />
  96. 96. Condylar and Subcondylar<br />Relative indications<br />Bilateral condylar fractures to preserve vertical height<br />Associated injuries that dictate earlier function<br />Soft tissue swelling causing airway compromise with MMF<br />Intracapsular fracture on opposite side where early mobilization important<br />
  97. 97.
  98. 98. Panfacial fractures<br />Expose all fracture sites<br />Reconstruct the AP projection of face, start from stable post area (temporal bone, proximal arch<br />Reconstruct the width of the face across zygomatic arches (frontozygomatic suture)<br />Recreate NOE area.<br />Restore height (fix ramus fractures)<br />Restore occlusion.<br />Repair the fractures in maxilla and mandible closer to teeth bearing areas<br />KVS<br />
  99. 99. TMH statistics 2010-11<br />KVS<br />
  100. 100. TMH statistics 2010-11<br />KVS<br />
  101. 101. TMH statistics 2010-11<br />KVS<br />
  102. 102. Thank you<br />
  103. 103. KVS<br />

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