Maxillofacial Trauma

Presented Dr. Hashem Hassouna PhD.

Lecturer Oral Maxillofacial Surgery
PUA. Alexandria
 Over View

Types of soft tissue injuries.

Primary assessment

Generalized clinical features of facial trauma.

Sites of Fracture mandible and maxilla.

Specific treatment for each type of fracture.

Maintaining post operative treatment.

complications

Dr. Hashem Hassouna (

 Learning Objectives

Recognize injuries of soft tissues+ oral mucosa.

List causes of facial injuries

Injuries of jaws including dent alveolar fracture.

Describe first assessment care for maxillofacial
injuries.

Understand the different methods for fixation

Describe post operative care

Recognize complications associated with
maxillofacial trauma.
Dr. Hashem Hassouna ,
 Soft Tissue Injury:

• It is important to dentist to know and

differentiate between severe soft tissue
injuries that is involved with facial trauma
I. Abrasion
II. Contusion
III. Laceration
 I. Abrasion
A wound caused by friction between hard object and
surface of soft tissue.
Specification :
01 Superficial layer-denudes epithelium may involve deep
epithelium
(1 Painful as affected terminal nerve fibers
,1 Minor bleeding and responds to gentle pressure
31 Common seen on lips or on the tip of the nose cheecks
and patient chin associated with dentoalveoalar trauma
Abrasion is very common during dental practice:

bur usage rotation laceration accidentally to mucosa

gauze pack abrade the mucosa during removal
Management :
0. Cleaning of wound.
(. Removal of dirt and sands-foreign material with
cleaning saline to prevent tattoo result.
,. Topical Antibiotics ointments applied with loose
bandage.
3. Systemic antibiotic is not recommended .
4. After a week reepithelization will occur under
eschar(crust of dried blood+serum1 which will
then drop off.
6. If deep abrasion i.e. Large area is discovered skin
grafting is indicated to prevent scar formation.
Abrasion with reepitheliazation Eschar
 II. Contusion
Result from impact trauma to hard or soft
structure resulting submucosal and SUBDERMAL
hemorrhage with NO OPEN WOUND
Specification :
01 Associate with trauma to dentoalveolar fracture
(1 Hematoma formation from capillary leading
subcutaneous hemorrhage(Petechea1
,1 Swelling.
31 Pain.
 Management:Contusion
0. Hydrostatic pressure Hematoma resorption “Ice Pack
in the first (3 hours, then a hot pack is used. And a
Hemoclar ointment is used
(. Normal contour is reestablished and ecchymosis is
seen (purplish discoloration extravasations of blood
into skin+mucosa(blue-black color1 and turn to fading
into blue-green and yellow color before fading that
extend to the chest- clavicles
,. Antibiotic is not recommended other wise a
compound or comminuted dent alveolar fracture
3. Painkillers.
4. Prevention of infection
Contusion
 III. Laceration
Tear of epithelial + sub epithelial tissue .
Injury by sharp object as knife or glass
Blunt object leading to jagged+ torn wound
Specification :
01 Involve extend into deep tissue
(1 Disrupting nerves-blood vessels-muscles
,1 Common in lips, floor of the mouth, labial mucosa,
buccolabial vestibule and gingiva
31 Labial retraction for examination of labial vestibular
laceration is seen in dentoalveolar fracture
41 Soft tissue laceration is treated after hard tissue injury
Management:- four major steps for treatment laceration
 Cleansing of wound:- under anesthesia, saline- foreign
material
 Debridement wound: devitalized tissue jagged piece
of surface tissue to rich blood supply
" Hemostasis of wound: clamped tied with ligature
cauterized with electrocaugularion labial artery is
transverse the lower lip
$ Closure of wound:
0. Small palatal-intraoral laceration is not recommended for
closure
(. Proper positioning of all tissue layers depends on location+
depth of laceration and tongue, floor of mouth, lips –
antibiotics, antitetanus and adhesive strips external to
support healing
 Fracture of Jaws andDento alveolar
process
Definition: Fracture is sudden violent solution of
continuity of bone may be complete or incomplete in
character
Causes:
0. Falls/ RTA/ Sports injury/ Epileptic Seizures
(. Gun shot wounds
,. Wrong usage of elevators for removal impacted
teeth(Tuberosity / Alveolar process/Angle Mandible1
3. Pathological fracture: Associated with large Cyst/
Benign-malignant tumors/ Osteogenic -Imperfecta/
Osteoporosis/Osteomalacia/Osteomyelitis
 Classical Signs and Symptoms of
Fracture of Jaws and Alveolar process
0. History of injury to the area
(. Pain during movement
,. Interference with function
3. Abnormal mobility
4. Malocclusion
6. Deformity and facial asymmetry
@. Swelling and Ecchymosis depending site of
fracture
A. Crepitus
B. Absence of transmitted movement
 Facial Trauma
• Trauma of facial region frequently result in
injuries of soft tissue-teeth –maxilla- mandible-
zygoma-naso-orbital- ethmoid complex and
supraorbital region
• Injuries of facial skeleton combination
• Their combination with other areas of the body.
• Fundamental Fracture Treatment is through:
a1 Reduction
b1 Fixation
c1 Immobilization

Dr. Hashem Hassouna 0B

 Diagnosis of Fractures:
I Clinical Examination:
a) General clinical Examination
b) Local clinical Examination
II Radiographic Examination:
 I. Clinical Examination:
a) General Clinical Examination
0- Head injury and level of Consciousness: Measurement of
Consciousness through: Glasgow coma Score/
Trauma score(GCS+ respiratory rate +BP+ PR1
Severity of injury Score (Mild- Moderate-Severe
without life threatening- Severe with life
threatening
(- Eyes: Neurological examination. Injury to Globe.
Vision/ Pupil reaction to light should be
recorded.
 The Glasgow Coma Scale
• The Glasgow Coma Scale (GCS1 is the most common scoring system
used to describe the level of consciousness in a person following a
traumatic brain injury. Basically, it is used to help gauge the severity
of an acute brain injury. The test is simple, reliable and correlates
well with outcome following severe brain injury.
• The GCS is a reliable and objective way of recording the initial and
subsequent level of consciousness in a person after a brain injury. It
is used by trained staff at the site of an injury like a car crash or
sports injury, for example and in the emergency department and
intensive care units
• Every brain injury is different, but generally, brain injury is classified
as:
• Severe: GCS ,-A (You cannot score lower than a ,.1
• Moderate: GCS B-0(
• Mild: GCS 0,-04
 Glasgow COMA SCALE

Patient’s score determines category

Patient’
of neurologic impairment
impairment::

15 Normal .
13 or 14 mild injury.
injury.
9–12 = moderate injury
3–8 = severe injury
injury..
 ,. The Spine: palpate the whole spine cervical area
3. The Limbs: bone deformity and tenderness/
hematoma

4. Abdomen& Chest: Inspection/ Palpation of Visceral

injury (spleen injury1/ Chest respiratory movement/
Urine specimen for blood presence

6.Soft Tissue Lacerations: Facial tissue injuries must be

repaired gently before edema formation within 0-A
hours.
Proper examination under direct light.
 b) Local Clinical Examination:
Inspection Extra-orally:
• Ecchymosis, Swelling, Laceration and deformity of
bony contour/ facial symmetry.
• Hemorrhage/ Cerebrospinal Fluid
• Anterior Open Bite, Saliva dripping and blood as
most is compound into mouth.
Palpation Extra- Orally:
• Condylar area and Movement/ Contour of
Mandible
• Tenderness & Step Deformity
• Anesthesia mandibular nerve/ infraorbital n.
 CSF Leakage
The leakage is usually through: -
1- Ear
2- Nose
• It’s presence is an indicative of Fracture of the base of the skull
• CSF is the same color as Mucus
To differentiate between CSF and Mucus: -
1- Lab investigation
Due to the fact that Mucus has starch in it, two more tests can be done
2- Let the fluid dry on a piece of gauze and if the end result is starch then it’s
mucus otherwise it’s CSF
3- Via tasting “Last resort” → If it’s salty then it’s CSF otherwise it’s Mucus
To stop the bleeding a Vaslinated Gauze Is packed inside the nose + Ice Pack
Epistaxes due to trauma shouldn’t be treated until the presence of CSF
leakage has been eliminated
Might be fatal or lead to encephalitis
halo sign (or ring sign1
 Inspection Intraorally:
• Broken teeth/ Foreign Body/ Denture/
Coagulated Bld
• Buccal Sulcus for ecchymosis and hematoma .
• Lingual Sulcus ecchymosis pathognomonic.
• Occlusal plane/ Step deformity/ Teeth condition
• Falling of the palate
Palpation Intraorally:
• Lingual& Buccal examination
• Full mandibular movement
• Full examination of teeth(carious/ mobility1
 II. Radiographic Examination:
A Extra-Oral Radiographs:

Postero –Anterior:(Body, Angle/ Displacement1

Lateral Oblique Rt & Left( Body/ Angle / Condylar neck1

Towne’s View and reverse

Occiptomental/ Water’s view

OPG
B. Intra-Oral Radiograhs:
 Occlusal view/ Oblique occlusal view
 Periapical view
 Extra Views as: CT scan/ Tomograms/ Transcranial/ MRI/
Ultrasonograph/ CSF scintigraphy.
Evaluation of patient with Facial trauma

 A= airway maintenance+ cervical spine

 B= breathing + ventilation
 C= circulation + hemorrhage control
 D= disability + neurological status
 E= examination complete patient body

Dr. Hashem Hassouna ,H

 First Aid Treatment:
The primary survey should take no longer than  to  minutes
and based on the ABCs:
* Airway maintenance with cervical spine control,
* Breathing and adequate ventilation, and
* Circulation with control of hemorrhage
*Degree of consciousness (Disability )
*Exposure of the patient via complete undressing to avoid
injuries being missed because they are camouflaged by
clothing
 First Aid Treatment:
• First aid treatment as following:
01 Control of Airway
(1 Control of Hemorrhage
,1 Control of Shock
31 Control of Infection and Pain
41 Transportation
 01 Control of Airway
• It is the most important considerations in
management.
• Causes of Obstructions:
01 Accumulation of Bld Clot in mouth+ Oropharynx
(1 Broken teeth- parts- denture
,1 Obstruction by foreign body
31 Falling back of the tongue unconsciousness patient
41 Maxillary fracture cause Fall of soft palate
61 Bilateral Parasymphesis region leading posterior
displacement
 Control of Airway( continue1
• Prevention to get Clear airway as follow:
01 Patient in prone position this allows Bld,
Vomitus through oral cavity
(1 Suction apparatus is used
,1 Tongue pull out by finger, Tongue forceps /
Stitch
31 Oropharyngeal airway- Nasopharyngeal
piece
41 Advanced Tracheostomy if needed
 (1 Control of Hemorrhage:
01 BP monitoring.
(1 Internal Hemorrhage lead hypovolemic shock.
,1 bleeding major vessel could be stopped through
ligation
31 Pressure pack Lacerated tissue for stopping Bleeding.
41 Identification source of Bleeding either from bone
/soft tissue/ Arterial/ Venous
,1 Treatment of Shock:(oligaemic/Psychogenic1
• Manifestation:
01 Pale clammy skin
(1 Disorientation
,1 Restlessness
31 Low systolic pressure
41 Deep respiration due to Air hunger
Causes:
I. Head Injury
II. Fear and Pain
III. Blood loss
IV. Air way Obstruction lead to brain hypoxia
 Treatment of Shock:
0. Place patient Head lower than Feet level to
increase cerebral circulation
(. Sedatives+ analgesic to relief pain
,. Never give Morphia = respiratory depression
3. Corticosteroids for raise BP.
4. O( supply
 31 Control Pain& Infection
I) Control Pain: avoid powerful analgesics
which depress consciousness level &
respiration
Drawback of Morphine:
01 Increase risk of respiratory obstruction
(1 Depress cough reflex= aspiration blood.
,1 Pupil constriction= mask Intracranial
pressure

Diazepam IV & mild Analgesic is the best
 Control Pain& Infection(continue1
II1 Control of Infection:
0. Prevention of meningitis due to
cerebrospinal Rhinnorhea & Otorrhea
(. Tetanus prophylaxis
Prevention:

Penicillin does not pass Brain barrier so
preferable to
give Sulfonamide( Sulfadiazine1 4mg/0gm
every 6h. For 4 days
NB: ampicillin + Floxacillin prophylaxis
 41 Transportation:

Patient should not lay on their back as they may
develop respiratory obstruction

Patient must lying on their side in position allow
the tongue to fall forward and secretions dribble
out of the mouth

Care during transportation on Board to prevent
injury of the spine

Collar placement for cervical injury leading to
paraplegia

Patient is placed with maintaining patent airway.