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DENTAL READINESS TRAINING: FRACTURE DIAGNOSIS AND   INITIAL STABILIZATION  (Lecture to be used in conjunction with   “Hand...
War/Deployment Trauma Care   Trauma care is often performed in austere,    resource limited, and sometimes dangerous    f...
   “The military surgeon does what must be done,    rather than what could be done to the casualty before    either retur...
Etiology of Fractures   Motor vehicle    accidents   Assaults   Falls/Accidents   Sports injuries   Other etiologies
Epidemiology of Facial Fractures Males > females; 3 to 1 Most prevalent age range: 16-30 year old Concomitant injuries ...
Anatomic Region Classification   Condylar process   Coronoid   Ramus   Angle   Body   Symphysis or    Parasymphysis...
Classifications of Fractures   Simple or closed    fracture   Compound or open    fracture   Comminuted fracture   Gre...
Favorable/Unfavorable Fractures
Favorable/Unfavorable Fractures
Diagnosis of Fractures Organized systematic evaluation Dynamic process-    – Maintain a high index of suspicion    – Fre...
History   Mechanism of injury   Previous facial    trauma/TMJ disorders   Preinjury occlusion   Past medical history ...
Physical Examination    “Look with fingers and eyes” Swelling and Ecchymosis Tenderness to palpation Malocclusion Defo...
Physical Examination“Look with fingers and eyes”
Dental Examination   Loose, fractured, avulsed teeth   Presence or absence of teeth    – Dentate, partial dentate,      ...
Radiographs   Panographs   Mandible series    –   Reverse Towne’s    –   Posteroanterior    –   Right and left lateral  ...
Objectives of Temporary          Stabilization Increase patient comfort Minimize further tissue damage Protect airway ...
Temporary Stabilization Methods Barton’s bandage Wire/composite or orthodontic brackets Simple “bridle” wire Ivy loops...
Barton Bandage
Simple “Bridle” Wire   Temporary reduction    and stabilization   25 or 26 gauge wire    and local anesthesia   Wrap ar...
Ivy Loops
Continuous Loop
Splints for Fixation
Maxillomandibular Fixation        (MMF)
Goals of Maxillomandibular             Fixation (MMF)   Restore occlusion   Reduction of    fracture segments   Stabili...
Types of Arch Bars   Erich    – More malleable   Winters    – Stiffer/less malleable   Custom   Others
Equipment   Wire drivers x 2   Wire cutters   Minnesota retractors   Local anesthesia   Suction   Orthodontic elasti...
Equipment   Wires    – 25 or 26 gauge    – Straight wires       » Interdental    – Wire “fishes”       » Interarch for MMF
MMF: Key Points   Interdental wiring    – 25 or 26 gauge wires Pass and secure below height of contour of  permanent tee...
MMF: Key Points Hooks on arch bars placed towards gingiva Pre-stretch wires Twist wires in a clockwise direction Apply...
MMF: Key Points Start securing arch bar in premolar region  on one side than work around arch Use Minnesota retractor to...
MMF: Pitfalls Overextended arch bars impinge on buccal and  anterior ramus mucosa Tails of protruding dental wires impin...
MMF: Case Presentation   60 y/o male with    cardiogenic syncope    who fell and struck    face on pavement   Left subco...
MMF: Case Presentation
MMF: Case Presentation
MMF: Case Presentation
MMF: Case Presentation
MMF: Case Presentation
Adjunctive treatment Hydration and nutrition Antibiotics    – All fractures through dentate region/open fx    – Fracture...
Adjunctive Treatment Close all lacerations within 12 hours of  injury, if possible Pain management: Avoid over-sedation...
Special thanks to the residents/staff of the OMFS Residency Programat the 59 MDW, Lackland AFB, TX and Col Jeff Armstrong ...
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Fracture stabilization

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Fracture stabilization

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Fracture stabilization

  1. 1. DENTAL READINESS TRAINING: FRACTURE DIAGNOSIS AND INITIAL STABILIZATION (Lecture to be used in conjunction with “Hands-on” fracture stabilization lab) Thomas W. Beckman, Lt Col, USAF, DC Oral and Maxillofacial Surgery Keesler AFB, MS
  2. 2. War/Deployment Trauma Care Trauma care is often performed in austere, resource limited, and sometimes dangerous forward deployed sites Care is by echelon- goal oriented Forward-deployed care of maxillofacial injuries is limited to emergency/initial care and stabilization Treatment of facial fractures can usually be deferred for up to 7-10 days after injuries – definitive care is done after Air Evac out of AOR
  3. 3.  “The military surgeon does what must be done, rather than what could be done to the casualty before either returning him to his unit or rendering him transportable to the next higher echelon of medical care.” Brig General Thomas Bowen
  4. 4. Etiology of Fractures Motor vehicle accidents Assaults Falls/Accidents Sports injuries Other etiologies
  5. 5. Epidemiology of Facial Fractures Males > females; 3 to 1 Most prevalent age range: 16-30 year old Concomitant injuries are common – 1.5 to 1.8 fractures/patient – Nasal fractures most common – Mandible/Zygoma/Maxilla : 6/2/1 – Must rule out spinal injuries – Dental injuries are commonly associated with other facial fractures
  6. 6. Anatomic Region Classification Condylar process Coronoid Ramus Angle Body Symphysis or Parasymphysis Alveolar process
  7. 7. Classifications of Fractures Simple or closed fracture Compound or open fracture Comminuted fracture Greenstick fracture Pathologic fracture Favorable vs Unfavorable fracture
  8. 8. Favorable/Unfavorable Fractures
  9. 9. Favorable/Unfavorable Fractures
  10. 10. Diagnosis of Fractures Organized systematic evaluation Dynamic process- – Maintain a high index of suspicion – Frequent re-examination and monitoring History Physical examination Ancillary studies Diagnosis/Treatment plan
  11. 11. History Mechanism of injury Previous facial trauma/TMJ disorders Preinjury occlusion Past medical history Psychiatric history Social history Special nutritional requirements
  12. 12. Physical Examination “Look with fingers and eyes” Swelling and Ecchymosis Tenderness to palpation Malocclusion Deformity of contour/asymmetry Limited motion/loss of function Abrasion/Lacerations Altered sensation Unnatural mobility/crepitus across fx site
  13. 13. Physical Examination“Look with fingers and eyes”
  14. 14. Dental Examination Loose, fractured, avulsed teeth Presence or absence of teeth – Dentate, partial dentate, edentulous Type of teeth present – Permanent, deciduous, or mixed Relationship of teeth to fracture Quality of teeth/periodontium
  15. 15. Radiographs Panographs Mandible series – Reverse Towne’s – Posteroanterior – Right and left lateral obliques Occlusal & periapical radiographs Computer Tomography
  16. 16. Objectives of Temporary Stabilization Increase patient comfort Minimize further tissue damage Protect airway Stabilize patient for transport
  17. 17. Temporary Stabilization Methods Barton’s bandage Wire/composite or orthodontic brackets Simple “bridle” wire Ivy loops/Continuous loops Arch bars Lingual/occlusal or “Gunning” splints
  18. 18. Barton Bandage
  19. 19. Simple “Bridle” Wire Temporary reduction and stabilization 25 or 26 gauge wire and local anesthesia Wrap around two teeth on either side of fracture
  20. 20. Ivy Loops
  21. 21. Continuous Loop
  22. 22. Splints for Fixation
  23. 23. Maxillomandibular Fixation (MMF)
  24. 24. Goals of Maxillomandibular Fixation (MMF) Restore occlusion Reduction of fracture segments Stabilization of fracture segments
  25. 25. Types of Arch Bars Erich – More malleable Winters – Stiffer/less malleable Custom Others
  26. 26. Equipment Wire drivers x 2 Wire cutters Minnesota retractors Local anesthesia Suction Orthodontic elastics – 8 oz.
  27. 27. Equipment Wires – 25 or 26 gauge – Straight wires » Interdental – Wire “fishes” » Interarch for MMF
  28. 28. MMF: Key Points Interdental wiring – 25 or 26 gauge wires Pass and secure below height of contour of permanent teeth Avoid piercing the gingiva if possible Arch bar – Proper length – Malleable (reduces orthodontic tooth movement)
  29. 29. MMF: Key Points Hooks on arch bars placed towards gingiva Pre-stretch wires Twist wires in a clockwise direction Apply forces apically when tightening wires Keep wire above arch bar (away from CEJ) on teeth next to fracture sites and on distal sides of teeth
  30. 30. MMF: Key Points Start securing arch bar in premolar region on one side than work around arch Use Minnesota retractor to stabilize arch bar while tightening wires Use wire director (“pickle fork”) to hold wire below cingulum on lingual of the anterior teeth Lightly tighten all wires then do final tightening after cutting wires short
  31. 31. MMF: Pitfalls Overextended arch bars impinge on buccal and anterior ramus mucosa Tails of protruding dental wires impinge on mucosa of the lips Interdental wires become loose and ineffective because of poor placement MMF is ineffective if too few teeth are secured
  32. 32. MMF: Case Presentation 60 y/o male with cardiogenic syncope who fell and struck face on pavement Left subcondylar fracture Multiple missing teeth and #17, 18 requiring extraction
  33. 33. MMF: Case Presentation
  34. 34. MMF: Case Presentation
  35. 35. MMF: Case Presentation
  36. 36. MMF: Case Presentation
  37. 37. MMF: Case Presentation
  38. 38. Adjunctive treatment Hydration and nutrition Antibiotics – All fractures through dentate region/open fx – Fractures in sinus – Dirty/old injuries Check tetanus status
  39. 39. Adjunctive Treatment Close all lacerations within 12 hours of injury, if possible Pain management: Avoid over-sedation While in Maxillomandibular fixation – Tooth brushing/chlorhexidine rinse – Wire cutters on patient at all times – No alcohol – High calorie blenderized/non-chew diet
  40. 40. Special thanks to the residents/staff of the OMFS Residency Programat the 59 MDW, Lackland AFB, TX and Col Jeff Armstrong for someof the photos and cases used in this presentation.

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