Management of facial fractures

Collected by: ahmadnejad _sahar

Subject: oral-surgery seminar
DMD 4C
Trauma to the facial region frequently
results in injuries to:
Soft tissues
Teeth
Mandible
Maxilla
Zygoma
Nasoorbital-ethmoid
complex
Supraorbital structures
Evaluation of patient with facial trauma:
Immediate assessment:
 1.evaluate the patient to assess patient`s Evaluation of cervical spine
cardiopulmonary stability:
How?
should be completed next.
I. Ensuring the patient has patent airway Any prosthetic, avulsed teeth,
II. Vital sign including :respiratory pulse should removed immediately
rate, blood pressure For injuries such as fractured
• 2.life-threatening problems should
also be addressed such as: excessive larynx should do emergency
bleeding by: tracheostomy
I. Pressure dressings
II. Packing and clamping of briskly
bleeding vessels.
History and physical examination:
The history should 1.how did the accident occur?
be obtained from 2.what are the specifics of the
patient or from the injury, including the type of
witness or
object contacted, the direction
accompanying
family members: from which contact was made.
And similar logistic
There are 5 considerations?
important questions 3.When did the accident occur?
that should be
4.Was there a loss of
considered:
consciousness?
5.what symptoms are now
being experienced by the
patient, including pain, altered
sensation, visual changes, and
malocclusion?
There should be a complete
review of systems, including
information about allergies,
medications, and previous
tetanus immunization, prior
surgeries.
In physical examination:
Face and cranium should
be carefully inspected for
evidence of lacerations ,
abrasion, contusions, area
of edema or hematoma
formation and contour
defect.
Periorbital echymosis with
subconjuctival hemorrhage
is often indicative of orbital
rim or zygomatic fractures
 Bruises behind the ear or battle`s
sign suggest a basilar skull
fracture
 Ecchymosis in the floor of the
mouth usually indicates an
anterior mandibular fracture.
 For neurologic examination
check all of the cranial nerves
 Visual acuity or pupillary
changes may suggest intracranial
or direct orbital trauma.(II and
III dysfnx)
Papillary change anisocoria
Uneven pupils (anisocoria)
in a lethargic patient
suggest an intracranial
bleed (subdural or epidural
hematoma)
Irregular pupil is caused by
a globe(eyeball) perforation
Abnormalities of ocular
movements indicate either
central neurologic
problems(III, IV, or VI)
Any laceration should be
cleaned and evaluated.
Motor fnx of facial
muscles (VII) muscles of
mastication (v)
For mandible bimanual
palpation of the suspected
fracture area.mobility of
the teethin the area of
possible fracture
Evaluation of midface
includes the checking for
the mobility of maxilla
and zygoma, and nasal
bones in evaluate of arch
fracture the index finger
should be inserted to the
maxillary vestibule
adjacent to the molars
INTRAORAL INSPECTION
SHOULD INCLUDE AREAS OF
MUCOSAL LACERATION, OR
ECCHYMOSIS IN THE BUCCAL
VESTIBULE OR IN THE PALATE
AND EXAMINATION OF THE
OCCLUSION AND AREA OF
LOOSE MISSING TEETH.
Open bites are highly suspicious
for some type of jaw fracture
Radiographic evaluation:
Purpose of radiographic
examination is to confirme
the suspected clinical
diagnosis.
 For mandible: 4 types of
radiograph views:
1) Panoramic view
2) Open-mouth towne`s
view
3) Posteroanterior view
4) Lateral oblique views
For supplemental radiograph
we have:
1) Occlusal view
2) Periapical view
o CT scan can help in
supplemental information
o For evaluation of midface
fracture there is
supplemental of waters`
view, lateral skull view,
posteroanterior skull view,
and submental vertex view
Cause and classification of facial fractures:
Cause of facial fractures: Mandibular fractures:
 Motor vehicle accident Several location depending
 Falls and sport-related on the type and direction of
incidents force
 Work-related accidents One classification of
mandible is according to
location of fracture:
1. Condylar(29.1%)
2. Angle of body (24.5 %)
3. Symphysis (22%)
4. Body of mandible (16%)
 5. alveolar region (3.1 Green stick: incomplet
%) fractures with flexible
 6.ramus (1.7%) bone
 7.coronoid process (1.3 Simple: complete
%) transection of the bone
 Another classification Commiunuted: is
of mandible fractures fracture which left
are:simple,greenstick,c multiple segments
ommiunuted, and ( gunshot wound )
compound fractures
 CO
Compound fractures: results
in communication of
fracture with external
environment
Any jaw fracture within a
tooth bearing segment is an
open or compound fractures.
Can be favorable or
unfavorable depending on
the angulation of fracture
and the force of the muscle
pull
COMPOUND
FRACTURE
Midface fractures:
THE MOST COMMON FACIAL
FRACTURE IS THE
ZYGOMATICOMAXILLARY
COMPLEX FRACTURE.
MIDFACIAL FRACTURES
INCLUDE FRACTURES
AFFECTING THE MAXILLA,
THE ZYGOMA.
LEFORT I RESULT FROM THE
APPLICATION OF
HORIZONTAL FORCE TO THE
MAXILLA WHICH FRACTURES
THE MAXILLA FROM THE
MAXILLARY SINUS.
LEFORT I FRACTURE
IT SEPARATES THE
MAXILLA FROM THE
PTERYGOID PLATES AND
NASAL AND ZYGOMATIC
STRUCTURES.
THIS TYPE OF TRAUMA
MAY SEPARATE THE
MAXILLA FROM OTHER
STRUCTURES AND CAN
CAUSE FRAGMENT THE
MAXILLA.
LEFORT II,FORCES ARE APPLIED IN A MORE
SUPERIOR DIRECTION.
WHICH SEPARATE MAXILLA FROM THE ORBITAL
AND ZYGOMATIC STRUCTURES.
LEFORT III FRACTURES RESULTS WHEN
HORIZONTAL FORCES ARE APPLIED AT A LEVEL
SUPERIOR ENOUGH TO SEPARATE THE MAXILLA
,NOE COMPLEX AND THE ZYGOMA FROM THE
CRANIAL BASE
LEFORT II FRACTURE
LEFORT III
Treatment of facial fractures:
Goals of the facial
treatment:
A)rapid bone healing
B)return of normal
ocular,masticatory
And nasal function
C)restoration of speech
D)acceptal facial and
dental esthetic.
To achieve these goals:
 Reduction of the fracture
 Fixation and stabilization of the
bony segments
 Immobilization of segments at
the fracture site
 restoration of preoperative
occlusion
 Treat as soon as possible
 In some cases a delay of 1 to 2 days
may cause tissue edema which
may eliminate by 3 to 4 days.
Facial fractures treatment
may begin in the area where
fractures can be most easily
stabilized and progresses to
the most unstable fracture
areas.
The surgeon should rebuild
the face based on primary
support in the vertical and
anteroposterior directions
There are three butresses exist bilaterally that
form the primary vertical support:
A. The nasomaxillary
B. Zygomatic
C. Pterygomaxillary butresse
 Structures that support the anteroposterior
direction include: frontal bone, zygomatic
arch, zygoma complex, maxillary alveolus, and
palate and the basal segment of the mandible
Mandibular fracture treatment
First and most important
aspect of correction is to
reduce the fracture or place
the individual segments
into the proper relationship
with each other.
Establishing the proper
occlusion by wiring termed
maxillomandibular fixation
(MMF) or intermaxillary
fixation (IMF)
Techniques:
Most common I. Arch bar
technique include the intermaxillary fixation
use of prefabricated arch II. IVY loop wiring
bar that is adapted and technique
circumdentally wired to III. Continuous loop
the teeth n each arch. wiring technique
The maxillary arch wire
is wired to the
mandibular arch wire
Heavy elastic traction can be
use to pull the bony
segments into their proper
positions gradually.
MMF is called CLOSED
REDUCTION
In the case of fractures in the
edentulous patient :
The mandibular denture can
be wired to the mandible
with circummandibular
wiring
And the maxillary denture to
the maxilla, then the maxillary
and mandibular denture will
wired together by MMF
Most of them will undergo
open reduction and internal
fixation (ORIF)
After 6 weeks new denture can
be fabricate
Use of splinting technique like
occlusal and lingual splint
specially in children
why splint?
In children the placement
of arch bar and bone plate
are difficult.
Because of the
configuration of the
deciduous teeth
Because of patient
understanding and
cooperation is difficult to
obtain
Indications for open reduction:
Continued displacement of bony segments
Unfavorable fracture
Note that rigid fixation techniques can decrease the
time of the MMF
For condylar fractures MMF can be used for maximum
of 2 to 3 weeks in adults and 10 to 14 days in children
Longer period can lead to: ankylosis, fibrosis and
severe limited mouth opening
After open reduction, direct surgical access:
Symphysis and anterior of Currently technique of
the mandible can be rigid internal fixation are
approach through :
intraoral incision Bone plate, bone screws,
The posterior or ramus or both
and condylar fracture
through extraoral
approach
Angle fracture and
posterior body by the use
of both approach
Advantage of the rigid internal fixation:
Decreased discomfort and Better postoperative
inconvenience to the management of patient
patient with multiple injuries
MMF is eliminated or
reduced
Improved postoperative
nutrition
Improved postoperative
hygiene
Greater safety for seizure
patients
The End
Thank you Dr.sotelo