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abscess advanced trauma life support anterior open bite antibiotics braces csf leaks dental diseases doxycycline dr dr shabeel drshabeel’s face eye trauma gingival infection medical medicine periodontal gum surgery pharmacy pn
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2. Even trivial blows to the face may
• compromise the airway
• directly or indirectly cause a head injury
• cervical spine injuries
Commonly from sporting activities, accidents and
intentional violence.
3. Immediate or delayed respiratory obstruction.
Immediate obstruction may arise from
- inhalation of tooth fragments
- accumulation of blood and secretions
-loss of control of the tongue in the unconscious or
semiconscious patient
Delayed obstruction may arise from oedema , which tends to
develop within 60-90 minutes
Sustained bleeding may be due to accompanying skeletal
fractures or a ruptured viscus
4. ▪ The patient should be nursed in the semiprone position
to allow secretions, blood and foreign bodies to fall
from the mouth.
▪ neck should be supported by a protective collar
Patients with facial injuries should not be
allowed to lie supine
5. Lacerations and Soft tissue
injuries
Systemic examination the bones
Dental Occlusion, Palpation of
mouth
Cranial Nerves
6. Systemic palpation of bones, starting from,
Vault of skull, including the occiput
Face is palpated from front, bilaterally from,
Supraorbital and
Infraorbital ridges
The Nasal bridge
The Zygomatic bone
Zygomatic arch
Temporomandibular joint
Ramus of Mandible
Angle of Mandible
Body of Mandible
Symphysis of Mandible
•Tenderness
•Swelling
•Step deformity
•Crepitus
8. ▪Paresthesia suggests a fracture proximal
along the course of nerve.
▪Facial nerve palsy fractured temporal
bone / penetrating parotid injury
▪Pupil size and light reflexes
▪Diplopia
•Cheek , upper lip floor of orbit
•Lower lip fracture of mandibular body
10. Wounds must be thoroughly cleaned of dirt and debris to avoid tattooing.
Replace tissues accurately, especially
Vermilion border of lips
Eyelids
Nasal contours
Muscles and underlying
tissues should be brought
together with absorbable
sutures so that edges of
wound lie passively within
2mm of their final position.
Fine monofilament
sutures(5-0 or 6-0) are used
to bring the wound edges
together AVOID INVERSION OF WOUND EDGES
11. FACIAL NERVE INJURY:
-PRIMARY REPAIR IS THE MOST
APPROPRIATE TREATMENT
PAROTID GLAND INJURY:
-A FINE CANNULA IS INSERTED
WITHIN MOUTH INTO PAROTID
DUCT AND ANATOMOSIS OF
SEVERED PORTIONS OF DUCT IS
DONE, WITH THE CANNULA KEPT
AS A STENT INSIDE THE DUCT FOR
14 DAYS
PAROTID DUCT CANNULA
12. Upper Third
above the
eyebrows –
involves frontal
sinus and
supraorbital
ridges
Middle Third
above the mouth
– Le Fort I,II,III
Lower Third
mandible
13. -Presence of depressed
frontal bone fractures and
fractures of the posterior wall
of the frontal sinus require
neurosurgical collaboration
-fractures of the anterior wall
of the sinus are treated with
reduction and fixation through
bicoronal scalp flap
15. LE FORT TYPE I
▪ # LINE RUNS ABOVE AND PARALLEL TO THE PALATE &
EFFECTIVELY SEPERATED ALVEOLUS AND PALATE FROM
THE FACIAL SKELETON ABOVE.
• CROSSES LOWER PART OF NASAL SEPTUM, MAXILLARY
ANTRA AND PTERYGOID PLATES.
TRANSVERSE
16. LE FORT TYPE II
• PASSES THROUGH THE ROOT OF NOSE, LACRIMAL BONE, FLOOR OF
ORBIT , UPPER PART OF MAXILLARY SINUS & PTERYGOID PLATES.
• ORBITAL FLOOR IS ALWAYS INVOLVED INFRAORBITAL NERVE
PYRAMIDAL
17. LE FORT TYPE III
• COMPLETE SEPERATION OF FACIAL BONES FROM CRANIAL BONES.
• # LINES RUNS THROUGH NASAL BRIDGE, SEPTUM AND ETHMOIDS,
AND THROUGH BONES OF ORBIT TO FRONTOZYGOMATIC SUTURE.
CRANIO-FACIAL DYSJUNCTION
18. •Upper part of face is first stabilised by bicoronal approach at the
vault of the skull
•Incisions in the lower eyelid are used to explore fractures of
orbital floor
•Lower part of Maxilla is approached through a gingival sulcus
incison above maxillary teeth.
•Reduction of Maxilla with Rowe’s disimpaction forceps which
grasp the palate between the nasal and palatal mucosa
■ Intermaxillary fixation screws or dental arch bars or eyelet wires
may be needed to achieve the correct occlusion
20. ▪ SECOND MC FRACTURED
BONE OF FACE AFTER
NASAL BONE.
▪ TRIPOD FRATURE , AS
ZYGOMA IS FRACTURED
AT ITS 3 PROCESSES
1) ZYGOMATICO-FRONTAL
2) ZYGOMATICO-TEMPORAL
3) INFRA-ORBITAL
21. • STEP DEFORMITY AT
INFRA-ORBITAL
MARGIN.
• FRACTURE IN
ORBITAL FLOOR MAY
CAUSE HERNIATION OF
ORBITAL CONTENTS
INTO MAXILLARY
SINUS.
22. •FLATTENING OF MALAR PROMINENCE.
• EPISTAXIS.
• ANAESTHESIA IN DISTRIBUTION OF INFRA-
ORBITAL NERVE
• TRISMUS-DEPRESSION OF ZYGOMA ON
CORANOID PROCESS.
• DIPLOPIA-ENTRAPMENT OF INFERIOR
RECTUS MUSCLE.
• SUBCONJUCTIVAL HEMORRHAGE
•OBLIQUE PALPEBRAL FISSURE -DISPLACEMENT
OF LATERAL PALPEBRAL LIGAMENT.
• PERIORBITAL EMPHYSEMA
24. • Gillies temporal approachan
incision in the hairline, superficial to the
temporal fossa, about 15 mm long, at
45° to the vertical.
•Zygomatic arch is elevated by Bristow
or Rowe elevator
26. ▪Regular postoperative observations
must be made for retrobulbar
haemorrhage
• Forced duction test to ensure no limitation of
movement of the inferior oblique and inferior
rectus muscles
27. DIRECT BLUNT
TRAUMA
ORBITAL FLOOR – WEAKEST PART , IS FRACTURED
HERNIATION OF SOFT TISSUE INTO MAXILLARY ANTRUM
INFERIOR OBLIQUE AND INFERIOR
RECTUS MUSCLES –
ENOPHTHALMOS AND DIPLOPIA
INFRA ORBITAL NERVE-
NUMBNESS OF CHEEK
TREATMENT: Defects of the orbital floor can be
made up with bone graft or with
synthetic materials like Titanium Mesh.
28. comminuted fractures
involving the nasal bones,
maxilla, infraorbital rims and
the frontal bones.
cause significant deformity
due to disruption of the
medial canthal ligaments may
cause traumatic telecanthus
(widened intercanthal distance)
29. Sites of Mandibular Fracture
inlcudes,
Condylar Neck-weakest
part,most frequent site
through unerupted teeth (the
impacted wisdom tooth)
where the roots are long (the
canine tooth).
The mandible may fracture directly
at the point of the blow, or indirect
transmission of the kinetic energy
causes a unilateral or bilateral
fracture of the mandibular condyles.
30.
31. PLATING HAS MADE LONG TERM JAW WIRING ALMOST REDUNDANT
INDIRECT REDUCTION
AND FIXATION BY
INTERMAXILLARY
FIXATION(IMF)
OPEN REDUCTION AND
RIGID INTERNAL
FIXATION WITH
TITANIUM FIXTURES
AND MINI PLATES
32. FRACTURES OF MANDIBULAR CONDYLES
DEVIATION OF
MANDIBLE TO THE
SIDE OF FRACTURE
Fixation of mandibular
condyles
■ If displaced or bilateral, with
significant occlusal disturbance,
surgical intervention will be
requiredOpen reduction and
fixation
■ Reduction and plating helps
prevent anterior open bite, due
to malocculsion
33. FACIAL INJURIES MAY CAUSE EITHER IMMEDIATE OR DELAYED RESPIRATORY
OBSTRUCTION
SEMIPRONE POSITION
AVOID INVERSION OF WOUND EDGES IN SUTURING FACIAL LACERATIONS
FRACTURE OF MAXILLA – LE FORT TYPE I – TRANSVERSE #, TYPE 2- PYRAMIDAL ,
TYPE 3 – CRANIOFACIAL DYSJUNCTION
ZYGOMATIC FRACTURES ARE TRIPOD FRACTURES
THE CONDYLAR NECK IS THE WEAKEST PART AND MOST COMMON SITE OF
MANDIBULAR FRACTURE
34. Prophylactic antibiotics like penicillin / amoxycillin and
metronidazone should be given in all facial fractures
Dexamethasone may help to reduce facial oedema
Air bag provision, seat belts, laminated windscreens,
and drink/drive laws help to reduce the orofacial injuries
Editor's Notes
The first 60 minutes following the injury is considered the “golden hour” – a critical phase where the emergency management may be life saving for the patient
Sporting injuries like boxing , cricket ball injuries, road trafffic accidents, intentional violence such as fist blow
Mouth and nasal passages form part of the upper aero digestive tract.Lacerations and fractures of the facial skeleton may give rise to
Immediately after injury , the patient may have good airway but then swelling of tongue facial and pharngeal tissues may then cause respirtaory compromise.
Pattern and extent of soft tissue injuries
Mandibular and maxillary fractures may involve the dental occlusion
Patient should be ask to bring teeth together
Infraorbital ecchymosis is panda sign
Whether maxillary and mandibular division fit together
Hematoma in floor of mouth indicates fracture of mandible
Any missing teeth or broken teeth should be carefully recorded
Panoramic oral radiograph
Any missing bones to be replaced with bone grafts to avoid cosmetic forehead depression postoperatively
NASAL pyriform aperture , medial and lateral walls of maxillary sinus. Running posteriorly to include the lower part of pterygoid plates
CRIBRIFORM PLATE
Guerin sign – hematoma at greater palatine foramen
Maxilla may thrust downwards and backwards along base of skull, posterior teeth of upper and lower jaw contact prematurely giving appereance of open mouth
oedema of soft palate and tongue causing respiratory obstruction
This creates potential dural tear and csf leak
Mount vernon box frame
Sch which will often have no posterior limit
Tear of antral mucosa causes epitaxis
And patient is unable to look upwards
30 – 60 degree occipito mental view
It is then deepened through the temporalis fascia
Fracture is then reduced by inserting bristow periosteal elevator
After reduction, zygoma can be check by palpating the bony prominences of zygomatic arch and lateral and inferior oribital rims
Fractures of zygoamatic bone may also accompany orbital floor fractures
the lower eyelid is retracted and the inferior rectus grabbed in the lower fornix. The globe can then be rotated upwards and should move freely. Any restriction in movement suggests entrapment of the infraorbital soft tissues, and the floor of the orbit should be explored as for a blow-out fracture (see below).
Infra orbital nerve –infraorbital region, upper lip and alar region of nose
Enophthalmos due to hernaition of orbital fat
Fracture should be treated within 10-14 days of original injury
Comminuted involving multilple bones such as
where a blow to the chin point may cause a direct fracture of the symphysis or parasymphysis of the lower jaw.
Near the mental foramen(3)
Direct fracture of symphysis and indirect fractures of both the condyles of mandible
Hematoma in floor of mouth is called coleman’s sign
FOR FIXATION OF MANDIBLE
SPLINTING UPPER AND LOWER ARCHES OF TEETH TOGETHER
Prior to introduction of these plating systems, patients often have their jaws wired together for a period of 6 weeks