WOUNDS AND INJURIES OF THE Traumatic tattoo

SOFT TISSUES OF THE FACIAL AREA  Abrasion produced by traumatic episodes that
Classification of wounds cause dirt, cinders, or other debris to ground
Contusion into the tissue
Abrasion Treatment:
Laceration  Mechanical cleansing
Penetrating wound  Local anesthetic solution is injected into the
Gunshot, missile and war wounds area
Burns  Scrub with detergent soap with sterile gauze
1. CONTUSION  Irrigate the area
 Bruise 3. LACERATION
 Usually produced by an  From a tear
impact from a blunt object  By sharp object such as metal
without breaking the skin or glass
 Affects the skin and  May involve underlying vessels
 subcutaneous tissue and nerves
 Causes self-limiting TREATMENT:
 subcutaneous hemorrhage  Should be treated within a few hours of the
TREATMENT: injury
 Observation  Complete cleansing of the wound
 Hemorrhage is self-limiting  Adequate debridement
 Nature’s reparative processes are usually  Complete hemostasis
sufficient to produce complete resolution  Proper closure of the wound
without surgical intervention  Adequate supportive therapy
2. ABRASION o Dressings
 Rubbing or scraping off of the o Prevention of infection
covering surface o Prophylaxis against tetanus
 From friction Failures in primary closure
 Usually, painful 1. Tight closure of the wound without provision
 Hemorrhage is not a problem for deep tissue drainage
 Superficial tissue damage 2. Inadequate use of pressure dressings
Treatment 3. Failure to close the mucosa on the oral surface
 Local therapy of superficially infected wound of the wound
 Cleansing of wound with soap 4. Secondary hemorrhage
 antiseptic solution 5. Secondary manipulation of the repaired wound
 Usually, dressing is not required 6. Inadequate antibiotic therapy
o Eschar serves to protect the wound 4. PENETRATING WOUND
forms rapidly  Usually puncture type wounds
o If infection develops under the produced by a sharp object
eschar, remove the eschar🡪local such as nail, knife, ice pick
application of antibiotic preparation  Usually, deep
with continued mechanical cleansing  Frequently involves other
 Systemic or parenteral antibiotic therapy structures such as mouth, nose, maxillary sinus
seldom necessary  May carry infection deep into the tissue
 Possibility of tetanus infection
5. Gunshot, missile and war wounds TRAUMATIC INJURIES OF THE TEETH
 Produced by gunshot, shrapnel or AND ALVEOLAR PROCESS
other projectiles Common causes of dentoalveolar injuries
 Vary in character depending on Falls
speed,shape, and striking angle of Motor vehicle accidents
the projectile
Sports injuries
Sub classification
Altercations
1. Penetrating
Playground accidents
o retained in the wound
2. Perforating Management of Dentoalveolar Injuries
o produces a wound of exit  History
3. Avulsive  Clinical examination
o large portions of the soft or osseous  Radiographic examination
structures are carried away or destroyed History
1. Who is the patient?
Treatment
2. When did the injury occur?
 General condition of the patient
3. Where did the injury occur?
 Measures to ensure an adequate airway
4. How did the injury occur?
(tracheostomy)
5. What treatment has been provided since the
 Arrest of hemorrhage
injury (if any)?
 Control of shock
6. Did anyone note teeth or pieces of teeth at the
6. BURNS site of the accident?
 Flames, hot liquids, hot metals, steam, acids, 7. What is the general health of the patient?
alkalizes, roentgen rays, electricity, sunlight, 8. Did the patient had nausea, vomiting,
ultraviolet light, irritant gases unconsciousness, amnesia, headache, visual
disturbance, or confusion after the accident?
Classification Of Burns
9. Is there a disturbance in the bite?
1. 1st degree
Clinical examination
o erythema of the skin
1. Extraoral soft tissue wounds
2. Intraoral soft tissue wounds
2. 2nd degree
3. Fractures of the jaw or alveolar process
o vesicle formation
4. Examination of the tooth crowns for the
presence of fractures or pulp exposure
3. 3rd degree
5. Displacement of teeth
o complete destruction of the
6. Mobility of teeth
epidermis and dermis,
7. Percussion of teeth
extending into or beyond the
8. Pulp testing of teeth
subcutaneous tissue
RADIOGRAPHIC EXAMINATION
Treatment 1. Presence of root fracture
Categories: 2. Degree of extrusion or intrusion
1. Supportive care 3. Presence of preexisting periapical disease
o Prevention and treatment of shock 4. Extent of root development
o Control of infection/aggressive use of 5. Size of the pulp chamber and root canal
antibiotic prophylaxis 6. Presence of jaw fractures
o Pain control🡪 sedation 7. Tooth fragments and foreign bodies lodged in soft
2. Local care of the wound tissues
o Cleansing of the wound
Classification of Dentoalveolar Injuries Pulpotomy
Crown craze/crack  Aseptic removal of damaged and inflamed pulp
Horizontal/vertical crown fracture tissue to the level of clinically healthy pulp
Crown-root fracture  Larger exposures in which the apex is not
Horizontal root fracture closed
Sensitivity  Temporary measure to maintain the vitality of
Mobility the radicular pulp until the apex is closed
Tooth displacement Crown Root Fracture
Avulsion
Alveolar process fracture
Goal in treatment of dentoalveolar injuries:
 Reestablishing normal form and
function of the masticatory apparatus
Treatment:
Crown craze or crack
 If the coronal fragment is still in place-must
 Crack or incomplete fracture of the enamel
without a loss of tooth structure be removed
 No treatment/ periodic follow up  If the fracture does not descend too far
examinations apically- restore
 If the pulp is involved – endodontic treatment
Classification: injuries to the Tooth Crown fracture  If the tooth is not restorable, removal is
Class I fracture indicated
o A fracture of only the enamel cap  alveolar fracture is found- extraction may be
of the crown of the tooth delayed for several weeks
Class II fracture Horizontal Root Fracture
o An injury extending into the
dentin but with no pulp exposure
Class III fracture
o An extensive injury to the coronal
portion of the tooth with a pulp  Involving apical third
exposure
 Involving middle third
Class IV fracture
 Involving cervical third
o A fracture occurring at or below
Treatment:
the CEJ of t he tooth
 If the fracture is above or close to the gingival
If pulp is exposed: pulp capping crevice- the tooth should be removed or the
1. Exposure is very small coronal fragment should be removed and do
2. Patient is seen soon after injury RCT
3. Patient had no root fractures  If mobile- reposition and firm immobilization
4. The tooth has not been displaced for 2 to 3 months
5. No large or deep fillings exist that might
Sensitivity
6. indicate chronic inflammation within the pulp

 Injury to the tooth- supporting structure,

resulting in sensitivity to touch and percussion
without mobility or displacement of the tooth
Treatment: ✓ Lateral displacement
 No acute treatment  Displacement of tooth in mesial or distal
 relieving the tooth from occlusal contact direction, usually into a missing tooth space
monitor periodontal and pulpal heal  Possible alveolar wall fracture
o Reposition
Mobility
🡪 splint
 Injury to the tooth- supporting structure,
🡪 follow up
resulting in tooth mobility but without
Avulsion
tooth displacement
✓ Complete displacement of tooth from its
 Mild mobility: relieve occlusal contact
socket
 Extreme mobility: splint
✓ Maybe associated with alveolar wall fractures
 Periodic observation
❖ Storage media:
Tooth mobility: Classification by Preston D. Miller
o Water
o Class 1: < 1 mm (Horizontal)
o vestibule of the mouth
o Class 2: >1 mm (Horizontal)
o physiologic saline
o Class 3: > 1 mm (Horizontal + vertical mobility)
o milk
Tooth displacement o cell culture media in specialized container
✓ Intrusion (Hanks
 Displacement of tooth into its socket o balanced salt solution)
 Usually associated with compression fracture Factors to consider before replanting avulsed teeth:
of socket
o Percussion 1. No advanced periodontal disease
• metallic sound 2. Alveolar socket should be reasonably
Treatment intact to provide a seat for the avulsed tooth
 Ortho 🡪extrude 3-4-week period, then splint 2- 3. No orthodontic contraindications
3 months 4. Extra alveolar period should be considered
 Mature apex🡪 RCT 5. Evaluate stage of development
 Deciduous (touching the follicle of
Alveolar process fracture
succedaneous tooth) 🡪
Treatment
 extraction
 Place the segment to its proper position
 🡪 Deciduous (not in direct proximity to the
 Splint
succedaneous tooth)
 Referral
o observe
 In doubt
o extraction
✓ Extrusion
 Partial displacement of tooth out of its socket
 Possibly no concomitant fracture of alveolar
 Bone
o Seat back into its socket
o Splint: 2-3 weeks
o RCT
 MANAGEMENT OF FACIAL FRACTURES Classification: Midface fractures
Evaluation
Immediate assessment
History and physical exam
Radiographic evaluation
Classification: Mandibular fractures Le Fort I
 Results from the application of horizontal
1. Location force to the maxilla
Condylar  Fractures the maxilla through the maxillary
Ramus sinus and along the floor of the nose
Angle  Fracture separates the maxilla from the
Body pterygoid plates and nasal and
Symphyseal  zygomatic structures
Alveolar  Separate the maxilla in one piece from other
structures, split the palate, or fragment the
Coronoid
maxilla
TYPE:
Le Fort II
Greenstick fractures  Separation of the maxilla and the attached
o Incomplete fractures with nasal complex from the orbital and zyomatic
flexible bones structures
o Usually exhibit minimal mobility Le Fort III
when palpated  Results when horizontal force s are applied at a
o Fracture is incomplete level superior enough to separate the NOE
Simple fractures complex, the zygomas, and the maxilla from the
o Complete transection of the cranial base, which results in a craniofacial
bone separation
o Minimal fragmentation at the Treatment of facial fractures
fracture site  Maximal rehabilitation of the patient
Comminuted fractures  Rapid bone healing
o Fractured bones are left in  Return of normal ocular, masticatory, and nasal
multiple segment function
Compound fractures  Restoration of speech
o Communication of the margin of  Acceptable facial and dental esthetic result
the fractured bone with the  Minimize the adverse effect on the patient’s
external environment nutritional status
 Achieve treatment goals with least amount of
Angulation of the fracture and the force of the discomfort and inconvenience possible
muscle pull proximal and distal to the fracture
Basic surgical principles: guide for treatment
✓ Favorable fracture 1. Reduction of the fracture
▪ Fracture line and the muscle pull resist 2. Fixation of the bony segments to immobilize
displacement segments at the fracture site
✓ Unfavorable fracture o Treat ASAP
▪ The muscle pull results in displacement of
the fractured segments
BUTTRESSES: Primary vertical support of the face Midface fractures
1. Nasomaxillary buttress
✓ NOE fractures:
2. Zygomatic buttress • Reproduce normal nasolacrimal and ocular
3. Pterygomaxillary function while repositioning nasal bones and
buttress medial canthal ligaments into an appropriate
position to ensure normal postoperative
BUTTRESSES: Anteroposterior direction esthetics
1. Frontal bar • Suspension wiring
2. Zygomatic arch and zygoma complex • Miniature and micro bone plate system
3. Maxillary alveolus and palate 0.6 TO 1.5MM (THICK)
4. Basal segment of the mandible o Screw for 0.7 to 2.0mm external
Managements thread diameters
o Closed reduction • Polymers of polyglycolic acid and polylactic
o Open reduction acid (resorbable plates and screw system)

Mandibular Fractures: Management Management:

✓ Maxillomandibular fixation/ intermaxillary o Virtual reconstruction
fixation o Stereolithographic modeling
• Erich arch bars o Intraoperative navigation
• Bone anchored arch bars (Stryker hybrid
MMF)
• Ivy loops
• Continuous loop wiring
*splinting technique
Condylar fracture:
• Adult: 2 to 3 weeks
• Pedia: 10 to 14 days

Management of fractures: open reduction: internal

fixation
✓ MMF: 3 to 8 weeks
✓ Rigid internal fixation:
• Bone plates
• Bone screws
Advantages:
1. Decrease discomfort and inconvenience
(minimal/no MMF)
2. Improve postoperative nutrition
3. Improve post operative hygiene
4. Greater safety for patients with seizures
5. Better postoperative management of
patients with multiple injuries
 COMPLEX ODONTOGENIC INFECTIONS
FASCIAL SPACES
fascial tissue spaces, or tissue spaces
fascia- lined areas that can be eroded or
distended by purulent exudate
Are potential spaces that exist between
the fascia and underlying organs and other
tissues
Primary maxillary spaces
1. Canine
o Between levator angulioros and levator labii
superioris muscles
o From maxillary canine tooth
2. Buccal
o Overlying skin of the face on the lateral
aspect and buccinator muscle on the medial
o Maxillary molars
3. Infratemporal
o Posterior to the maxilla
o Medial-lateral plate of pterygoid process
of sphenoid bone and superiorly by base of
skull; laterally à continuous with deep
temporal space
o Maxillary 3rd molar
Primary mandibular spaces
1. Submental
o Between anterior bellies of digastric muscle
and between mylohyoid muscle and overlying
skin
o Mandibular incisors
2. Buccal
o Overlying skin of the face on the lateral
aspect and buccinator muscle on the medial
o mandibular molar teeth
3. Submandibular
o Between the mylohyoid muscle anD
overlying skin and superficial fascia
o Posterior border communicates with
secondary spaces of jaw
4. Sublingual
o Tongue usually becomes elevated
Ludwig’s angina
 bilateral: submandibular, sublingual and
submental spaces
 Rapidly spreading cellulitis that commonly
spreads posteriorly to secondary spaces of the
mandible
 Severe swelling, elevation and displacement of
the tongue
 Tense, hard induration of submandibular region
superior to hyoid bone
 Trismus, drooling saliva, and difficulty in
swallowing and sometime breathing
 Maintenance of airway…
Secondary fascial spaces
1. Masseteric
o Between lateral aspect of the mandible and
the medial boundary of the masseter muscle
o From buccal space or infection from soft
tissue around mandibular 3rd molar
o Angle of the jaw and ramusa swollen
2. Pterygomandibular
o Medial to the mandible and lateral to medial
pterygoid muscle
o From sublingual and submandibular spaces
o (If alone) little or no facial swelling but
with trismus
3. Superficial (extend to temporal fascia)
and deep temporal (continuous with
infratemporal space)
o posterior and superior to the masseteric and
pterygomandibular spaces
4. Lateral pharyngeal
o base of the skull at the sphenoid bone to
the hyoid bone inferiorly
o styloid process and associated muscles and
o fascia divide:
• anterior compartment muscles
• posterior compartment carotid sheath
and several cranial nerves
o severe trismus, lateral swelling of the
o neck, swelling of lateral pharyngeal wall
toward the midline
o difficulty in swallowing, high temperature,
quite sick
Lateral pharyngeal: potential problems Osteomyelitis
o May progress at rapid rate  Inflammation of the bone marrow
o Direct effect of the infection on the  Begins in the medullary cavity, involving
contents: posterior: the cancellous bone spread: cortical
• thrombosis of internal jugular vein bone periosteum
 Mandible
• erosion of the carotid artery and its
 Body’s host defenses
branches
o Alcoholism
• interfere with CN IX-XII
o Malnutritional syndrome
o Progression to retropharyngeal space
o Diabetes
5. Retropharyngeal o Intravenous elicit drug use
o behind the soft tissue of the posterior o Myeloproliferative diseases (leukemia)
aspect of the pharynx ✓ Major predisposing factors:
o begins at the base of the skull and extends o Odontogenic infection
inferiorly to the level of vertebra C7 or T1 o Mandibular fractures
• infection can extend inferiorly to the o Acute suppurative osteomyelitis:no/little
posterosuperior mediastinum radiographic change
• extension to prevertebral space o Chronic osteomyelitis: “moth-eaten”
o evaluated with lateral radiographs of the appearance
o neck space is enlarged compromise ✓ Treatment:
o Medical and surgical
airway
o Clindamycin
6. Prevertebral
o separated from retropharyngeal space by Actinomycosis
alar layer of prevertebral fascia from the  Infection of the soft tissue of the jaw
pharyngeal tubercle on the base of the  Actinomyces israelii…A. naeslundii/A. viscosus
skull to the diaphragm  Recent tooth extraction, severely carious
o Potential complications: teeth, minor oral trauma
1. the serious possibility of upper airway  Lobular “pseudotumor”…multiple sinus tract
obstruction  Definitive diagnosis: laboratory identification
2. rupture of the retropharyngeal space ✓ Treatment:
abscess (with aspiration of pus into the o I&D, excision of all sinus tract
lungs and subsequent asphyxiation o Penicillin:4x/day for at least 3 months
3. spread of infection into the o Tetracycline (Doxycycline)
mediastinum Candidosis
Management of fascial space infections  Candida albicans
1. Medical support of the patient, with  Compromised health:
special attention to correcting host o Ø Prolonged administration of antibiotics
defense compromises where they exist o Ø Chemotherapy for leukemias and other
2. Administration of proper antibiotics in forms of cancer
appropriate doses  White patches that can easily rubbed off
3. Surgical removal of the source of infection with gauze to expose underlying red, raw
as early as possible surface
4. Surgical drainage of the infection with ✓ Treatment:
placement of proper drains o Topical antifungal agents
5. Constant reevaluation of the resolution of o Nystatin
the infection o Clotrimazole
PRIMARY AND SECONDARY LESIONS Papules
- are circumscribed elevated
PRIMARY LESIONS areas varying from pinhead
- A lesion directly associated with the disease to about 5mm.
process that is described with established - may be flat, conical, circular,
dermatological terminology pointed or umbilicated
- are present at the onset of a disease - color is from red, yellow, white to bluish
- Eight types of primary lesions that may occur in red
mouth or skin:
1. Macules
2. Papules
3. Nodules
4. Vesicles
5. Bullae Macule – flat
6. Tumors Papule – elevated, lichen planus
7. Keratoses Lichen planus – most common papule found in the
8. Wheals mouth; politic papular rash lace like wickham striea

Macules Nodules
o are flat circumscribed alterations - are enlarged papules usually
of tissue that may vary in size, deep-seated involving the
color and shape. submucosa or lower dermis
of the skin.
Types of Macules: - May also be slightly elevated
A. Vascular in origin -erythematous macule above the surrounding mucosa
B. Resulting from blood pigments-petechiae & - Ma be of traumatic origin or associated with
ecchymoses rheumatoid arthritis, leprosy, and syphilis.

C. Pigmentary macules
a. physiologic:
freckles or ephiledes
Treponema pallidum – syphilis
3 stages of syphilis:
b. pathologic:
1. Primary – chancre
Addison’s disease, Peutz Jeghers Syndrome
2. Secondary – rashes, nodules, patches
3. Tertiary – gumma
Mycobacterium leprae– leprosy

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Vesicles Tumor
- are circumscribed single or - etymologically means
group elevations of swelling or enlargement
epithelium of the skin and - means neoplasm or
mucous membrane beneath malignancy
or within which are collection of
serum, plasma or blood.
- May be seen characteristically in primary
herpetic stomatitis, herpes simplex, herpes
zoster, and varicella

Keratosis
- refers to abnormal
thickening of the outer layer
Pustules epithelium of the mucous
- Are vesicles that predominantly contains pus membrane or the skin.
- e.g., Impetigo - Chronic cheek biting, focal hyperkeratosis, and
nicotine stomatitis – most common forms of
hyperkeratotic lesions in the mouth
- Keratosis may be of primary origin, as in lichen
planus, or secondary to trauma as in nicotine
stomatitis
Bulla/ Bullae (BLEBS)
- similar to vesicles; however,
they are larger and more deep-
seated, and the roof of cavity is
more resistant to rupture than
that of the vesicle.
- may be seen in pemphigus, Behcet’s syndrome, Leukoplakia – white lesion
and Stevens-Johnson syndrome

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SECONDARY LESIONS - scrotal tongue, angular cheilitis, and syphilitic
- Lesion that appears consecutively to the rhagades show fissuring
primary lesions
- Modification of a primary lesion that results
from evolution of the primary lesion, traumatic
injury, or other external factors.
- Include:
1. Erosions (excoriations) Angular cheilitis -caused by a type of yeast (Candida)
2. Ulcers Cause of fissuring:
3. Fissures 1. Loss of vertical
4. Cicatrices dimension
5. Desquamation 2. Fungal
infection
Erosion
- Are kind of ulceration or loss Ulcers
of substance produced on - are defects of the skin or
the skin or mucous mucous membrane that are
membrane by trauma or as a deeper than erosions or they
sequela of primary extend to the tissues beneath
membrane. the epithelium
- superficial in nature and - may result from physical
maybe circumscribed, punctuate, linear agents such as heat or cold,
or irregular chemical agents such as acids or alkalies, or
- involves a loss of outer layer of mucosa and traumatic agents (bristles, sharp teeth)
leave no scar on healing

Candidiasis – one of the most frequently occurring

Fissures that develop into ulcer
- are clefts or grooves in the tissue
that are pathologically present. Pseudomembranes
- May be superficial or deep, - false membrane found in response of the
linear, radiating, longitudinal or mucous surface to a necrotizing agent.
transverse - loss of surface epithelium, plasma exudates
- occur frequently on from the vessel and spread in the eroded
mucocutaneous junction of the surface where it coagulates enclosing necrotic
mouth epithelium and its fibrotic network.
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 - Occurs in acute ulcerative gingivostomatitis - do not usually appear in mouth because of
and may also be seen in diphtheria maceration by saliva; however, they may be
associated with scales and are termed moist
desquamations
- are composed of pus, blood, dried serum,
epithelial debris, and extraneous matter
- color varies according to their composition -
maybe yellowish to brown depending on the
amount of pus or blood
Eschars
- are masses of dead tissue or sloughs produced
by burning or chemical corrosives.
- phenol and aspirin eschars are the most type
seen in the mouth causing a firm, thick dull
gray to brown eschars

- end -

Desquamation
- is the shedding of epithelial elements in scales
or sheets
- vary in size and shape -occurs as a result of
inflammation
- do not accumulate in the mouth because of the
continual wetting of saliva

Crust
- these are dry products of exudates from
lesions occurring on the skin and lips
- maybe associated with scales and are termed
moist desquamations

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