1. Management of
maxillofacial
injuries
Instructor – Dr. Jesus George
1

2. Introduction
The facial skeleton is divided into 3 parts
Upper 1/3-formed by frontal bone
Middle 1/3-from frontal bone to the level of upper
teeth
Lower 1/3-the mandible
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3. The causes of maxillofacial injuries
Fights
Falls
Road traffic accidents
Occupational hazards-athletic injury, industrial
mishaps
Iatrogenic causes-# of tooth, alveolus,maxillary
tuberosity,# of mandible during dental treatment.
3

4. Examination of patient with maxillofacial trauma
History of injury
Obtained from the patient or relatives or the witness
of injury.
Who-name,age,sex,address,phone number
When-date & time of injury.
Where-the surroundings of injury.
How-type of violence & direction of force.
4

5. Cont.
What-type of treatment given before the patient
comes here.
What- is the general health of the patient.h/o
allergy,bleeding disorders,any systemic bone
disease,neoplasm,arthritis
Previous h/o trauma
Length of unconciousness
5

6. Cont.
H/o
pain,vomiting,unconciousness,headache,vis
ual disturbances,confusion,malocclusion.
H/o amount of bleeding-from extraoral
wound,intraoral wound,nose,ear.
Blood group of patient
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7. Glasgow coma scale
Eye opening-(e)
4.opens eye spontaneously
3.opens eyes to voice
2.opens eyes to pain
1.no eye opening
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8. Cont.
Motor response(m)
6.obeys commands
5.localizes pain
4.withdraws to pain
3.abnormal flexor response
2.abnormal extensor response
1.no movement
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9. Cont.
Verbal response(v)
5.appropriate & oriented
4.confused conversation
3.inappropriate words
2.incomprehensible sounds
1.no sounds
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10. Clinical examination of maxillofacial injuries
Extraoral examination
Patient`s face is gently washed with warm saline or
water prior to examination.
Inspection
Length, breadth & depth of soft tissue wound is
measured.
Nose & ear are inspected for bleeding or csf leak.
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11. Cont.
Periorbital edema,ecchymosis,subconjunctival
hemorrhage are noticed.
Bruise behind ear-battle`s sign indicates skull #.
If patient is concious, vision is tested in both the
eyes.pupillary reactionto light,diplopia are noted
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12. Cont.
Motor function of facial &masticatory muscles are
noted.
Intranasal laceration, septum deviation are noted.
Palpation
Palpation is started at the back of the head for
wounds & bony injuries.
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13. Cont.
Then the palpation is done in the forehead, the
fingers are kept in the midline & go sideways over
supraorbital rims,infraorbital rims,zygomatic bones
& arch.
Areas of tenderness,step deformities or abnormal
mobility are noted.
Nasal bridge palpation is started from the top till the
nasal tip.
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14. 14

15. Cont.
CSF leak may form a` halo ` effect on pillow or bed
sheets-ring test.since CSF is more viscous it forms
the central circle encircled by blood.CSF will not
stiffen the cloth whereas other secretions do so.
TMJ evaluation is done by placing the index fingers
on preauricular area or on the external auditary
meatus.all movements are checked.
Palpate the inferior border,posterior border for
tenderness & deformity
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16. Intraoral examination
Inspection
Oral cavity is thoroughly irrigated prior to
inspectionmouth wash can be used.
Restriction of oral opening, gagging of
occlusion,lacerations,ecchymosis,damage to teeth &
alveolus are noted.
Buccal & lingual sulci are inspected for
wound,ecchymosis,sublingual hematoma
Loose teeth, occlusion are noted.
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17. Cont.
Step deformity in dental arch is noted.
Palatal mucosa is inspected for tear & bleeding.
Palpation
Buccal & lingual sulci are palpated for tenderness,
crepitus & mobility of teeth.
Mandible is palpated bimanually & unnatural
mobility is noted.
17

18. Cont.
For assessing maxillary mobility,patient`s head is
stabilized using one hand over the forehead & with
thumb & fore finger of other hand maxilla is grasped
with firm pressure to elicit maxillary mobility.
Rock the maxillary alveolar segments to detect
fractures of alveolus or split in palate.
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19. Radiologic examination
For # of middle 1/3 of face
PA view skull
Water`s view
Lateral view skull
Submentovertex view
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20. Cont.
For zygomaticomaxillary complex #
Water`s view
Submentovertex view
Ct scan
Pa view
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21. Cont.
For # of mandible
OPG
Right & left lateral oblique view of mandible
PA view mandible
Occlusal view
IOPA

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22. Basic principles to be followed for preservation of
life in a trauma patient
Maintenance of patency of airway
Bleeding control
Maintenance of circulation
22

23. Maintenance of airway
Position of the patient:-supine with neck
extended or head turned sideways.
Oropharyngeal toilet:-all blood clot,sliva thick
mucous, friegn bodies should be cleared by digital
exploration or by using cotton swabs.
Suction:-to clear nose,oral cavity &throat.
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24. Cont.
Anterior traction of tongue:-tongue is pulled
out & is held in position by tongue suture or towel
clip.
Restoration of position of soft palate:-by
disimpaction of maxilla.it is done by placing
index & middle finger hooking behind the soft
palate & thumb on the alveolus in the incisor
region.head is stabilized with the other hand over
the forehead.anterior & downward traction will
bring maxilla to normal position.
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25. Cont.
Mouth to mouth breathing
Oro or nasopharyngeal tubes
Tracheostomy
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26. Bleeding control
Compression dressing
Major vessels are clamped or ligated.
Soft tissue wounds are sutured.
Deep wounds are packed with guaze.
Nasal bleeding is stopped by using ribbon guaze
soaked in 1:1000 adrenaline.
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27. Maintenance of circulation:-
If the patient is in shock,iv fluids are started to
restore the blood volume.
After crossmatching blood transfusion is started.
Pulse,resp.rate,bp should be monitored.
Control infection by antibiotics & anti-inflammatory
analgesics through iv route.
Tt is given.
Adequate nutrition is given.
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28. Management of soft tissue injuries
Abrasions
Caused by frictional violence.
It is presented as raw bleeding areas.
Through cleaning is done with profuse saline
irrigation.
Remove the foreign materials.
Gentle scrubbing is done with soft brush to remove
sticky material.
Topical application of antibiotic ointment with
compression dressing is given
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29. Cont.
Superficial abrasions are covered with topical
antibiotic & is left open
Contusion
Caused by a blow or fall against a hard or blunt
object.
Blood extravasates in subcutaneous tissue leading to
bluish area or bruise.
Application of ice pack will help to stop further
extravasation .
29

30. Cont.
Hematoma
It is the localized collection of blood in subcutaneous
or intramuscular or submucosal space.
It may be associated with fracture or rupture of
vessels.
Most of them are reabsorbed.
Persistant hematomas may require incision &
drainage.
Antibiotic coverage is given to prevent infection of
hematoma.
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31. Cont.
Lacerations
Here tearing of mucosa or skin is seen.
There may be associated injury to
vessels,nerves,muscles & bone.
Thorough cleaning,minimum debridement,removal
of foreign bodies & proper suturing is done.
Suturing is done in multiple layers
31

32. Cont.
Incised wounds
Caused by sharp objects.
They are clearcut, gaping,bleeding wounds with
minimum contamination.
The wound is cleaned,bleeding is arrested.
Wound is closed by primary intension
Penetrating & punctured wounds
Caused by pointed objects.
Externally they appear small, but they may be deep
penetrating endangering vital organs.
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33. Cont.
Crushed wounds:-
Crushing of the parts with laceration is seen.
Crushing of musculature is seen.
Damage to blood vessels & nerves may be seen.
Bone may be shattered.
There may be loss of soft or hard tissues.
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34. Cont.
Gunshot injuries:-
They can be
 Penetrating wound-missile is retained in the wound
 Perforating wound-missile produces another wound of
exit.
 Avulsive wounds-large portion of soft tissue or bone is
desroyed.
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35. Supportive therapy of soft tissue wounds
Drains:-for deeper wounds in oral cavity drains
may be placed b/w sutures .it is removed after 2 to 4
days.
Dressings:-antibiotic ointment with dry guaze
dressing is changed in every 48hrs.sutuires are
removed on 5th
or 7th
day.
Prevention of infection:-sterile technique &
supportive antibiotic therapy.
Prophylaxis against tetanus
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36. Factors causing failure of wound healing
Too tight suturing.
Inadequqte pressure dressing.
Oral contamination of wound.
Secondary haemorrhage.
Inadequate antibiotic therapy.
Rough handling of wounds.
Foreign body inclusion.
Compromised vascularity.
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37. Cont.
Infection.
Constant movement.
Radiation.
Old age.
Anemia
Lack of vit.c.
Diabetes
Hapatitis
Steroid therapy
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38. Basic principles of management of
fracture
Reduction
Fixation
Immobilization
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39. Reduction
It is the restoration of fractured fragments to their
original position.
Reduction is brought about by closed reduction or
open reduction.
Closed reduction
It can be carried out by manipulation or by traction.
No surgical intervention is needed for closed
reduction.
Occlusion of teeth is used as the guiding factor.
39

40. Cont.
Reduction by manipulation
Done when the fragments are adequately mobile
witout much overriding or impaction & patient
comes immediately comes after trauma.
Digital or hand manipulation is used for reduction.
Disimpaction forceps or bone holding forceps can be
used.
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41. Cont.
Reduction by traction
Prefabricated arch bars are attached to maxillary &
mandibular arches by interdental wiring.
The fractured fragments are subjected to gradual
elastic traction by placing elastics from upper to
lower arch.
Open reduction
Surgical reduction that allows visual identification of
fractured fragments.
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42. Fixation
Fractured fragments are fixed to prevent
displacement & for achieving proper approximation.
Direct skeletal fixation :-by plates or intraosseous
wiring.
Indirect skeletal fixation:-by arch bar or
intermaxillary fixation.
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43. Immobilization
The fixation device is retained to stabilize the
reduced fragments until a bony union takes place.
For maxillary # 3 to 4 weeks immobilization is
enough.
For mandible # 4 to 6 weeks immobilization.
In condylar # 2 to 3 weeks immobilization to prevent
ankylosis.

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44. Arch bars
It has hooks incorported on the outer surface with
malleable stainless steel metal strip
The bar is cut to the length of dental arch.
Arch bar is fixed to both the arches.
On the upper jaw the hooks are arranged in upward
direction.
Archbar is adapted by bending the archbar starting
from the buccal side of last tooth.
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45. Cont.
The arch bar is fixed to the tooth with 26 guage
wire,one end of wire is above & the other below the
arch bar.
The twisting of the wire is done in clockwise manner.
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46. 46

47. Bone plate osteosynthesis
Indications
If imf is contraindicated
Edentulous patients with loss of bone segments.
If early mobilization of joint is required as in condylar #
Contraindications
Heavily contaminated # with active infection &
discharge.
Badily comminuted #.
In mixed dentition period.
Presence of gross pathologies in bone.
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48. Cont.
Precautions
Strict aseptic procedure is required.
Patient should be kept on preoperative antibiotics.
Plates and screws should be of same metal.
Minimum 2 screws should be used on each side.
The drill bit should be perpendicular to the cortex.
Patient should maintain good oral hygiene.
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49. 49

50. Cont.
Procedure
The intrafragmentary gap is less than 0.8mm .
Occlusal relationship is checked prior to screw
fixation.
Plates & screws are made up of stainless steel or
titanium & is removed later.
In compression bicortical screw system:-the outer
oblique holes produce additional compression.
50

51. Cont.
In monocortical noncompression screw system
(miniplte osteosynthesis):-stability is achieved by
perfect anatomic reduction & intrafragmentary
approximation without compression.
Miniplates are 2cm long.0.9 mm thick &6mm wide.
Screws have a thickness of 3.3mm.
The screws should be self tapping.
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