TRAUMATOLOGY

Traumatology
Maxillofacial
1. Traumatic lesions of the orofacial soft parts
1.2. Closed traumatic injuries of soft parts
1.2.1. Bruises
1.2.2. Haematoma
1.2.3. Seroma
1.2.4. Muscle stupor
1.2.5. Muscle crushing
1.3. Open traumatic injuries of soft parts
2. Traumatic lesions of the orofacial hard parts
2.1 Mandible fractures
2.2. Maxillary Fractures
2.3. Centrofacial fractures
2.4. Nose fractures
2.5. Lateral Fractures
1. TRAUMATIC LESIONS
OF THE OROFACIAL
SOFT PARTS
40-60% of all injuries
1.1. Aetiology

Traffic accidents
Accidents at work
Animal blows
Assaults by others
Accidental falls
Sports
Iatrogenic
■ Trauma from firearms
1.2. Closed traumatic injuries of
soft parts

BRUISES:
traumatic injuries caused by the action of vulnerable
agents in which the skin and mucous membranes remain
intact;
 Superficial, deep or mixed;
1.2.1. Bruises

■ Elemental lesion manifested by a congestive spot on

the skin or mucosa as a result of extravasation of
blood into the intercellular spaces;
1.2.2. Haematoma

 Extravasation of blood
following the rupture of
deeper and larger
vessels.
1.2.3.
SEROMA
1.2.4. Muscle Minimal muscle contusion
It is manifested by the temporary reduction or

stupor removal of the contraction force of the traumatized

muscle
■ Painful area, usually accompanied by bruises.
1.2.5. Muscle Total or partial compaction or rupture of muscle fibers between the
bone plane and the blunt body.

crushing It is usually accompanied by fractures.

■ Clinical: spontaneous pain and palpation, with local bruises, and
bone mobilization is very difficult.
 1.3 Open traumatic injuries of soft parts

Mucous wounds:
■ In the mouth, they are mainly observed at the level of the attached
gum (fracture of the mandible), at the level of the palatine fibro
mucosal (sagittal fracture of the maxilla), the tongue (bite following a
trauma on the chin), the veil of the palate (due to objects held in the
mouth at the time of the trauma: pencil, pacifier, for example), the
anterior oral floor and the palate (attempt at autolysis weapon held
under the chin).
Periorificial wounds (eyelids, nostrils, ears)
They range from the superficial wound only cutaneous or mucous membrane to the
transfixing wound
which will require precise identification of the banks to avoid any lag and repair
attentive to all levels (cutaneous, muscular, cartilaginous, mucous). Their gravity is
due to
their tendency to scar retraction, a source of ectropion in the eyelids and/or orifical
stenoses.

Skin wounds of the face

They can be superficial or deep, frank or contagious. They require
ensure the integrity of the underlying noble organs: facial nerve, parotid duct,
facial vessels.
Facial nerve wounds should be sutured under a magnifying glass or microscope after
spotting
severed ends.
 MANDIBLE
FRACTURES
■ A classic distinction is made
between fractures of the
mandibular body (fractures of
the toothed portions and the
angular region) and fractures of
the mandibular branches
(fractures of the non-toothed
portions and the condyle
region), the first being, by
definition, fractures most often
open, the second fractures
usually closed.
 AETIOLOGY
Traumatic
• aggression(accidents)
• traffic accidents
• accidental falls
• sports accidents
• gambling accidents
• accidents in rural areas
•
 CLASSIFICATION
1. Depending on the degree of fracture of the thickness of the bone:
- total fractures
- unique (2 unequal fragments)
- doubles (3 fragments)
- triple (4 fragments)
- comminutives

2. According to the participation of the periosteum:

- complete
- incomplete, crack in "green wood" – without displacement, (to children)

3. Depending on the relationship of the fracture with the oral cavity

- closed - rising branch
- working - horizontal branch (in edentulous)
 2.2. Pathogenesis
PRODUCTION MECHANISM
Impact between effector (dynamic) and receiver (static)
The architecture of the mandible influences the mode of action of the forces exerted on it -
an important fact not only for the mechanism of fracture production, but also for the logic of
treatment.
 The mandible has a set of areas of high and low resistance
2.2.
PATHOGENESI
S

AREAS OF INCREASED
RESISTANCE
LOW RESISTANCE
AREAS
 2.3. Classification
BY PRODUCTION MECHANISM
Direct fractures (pressure
mechanism)  Compression fractures
Bending fractures (flexion)
Compression fractures
 Shear fractures
 Shear fractures

 Bending fractures
(flexion)
2.3.
CLASSIFICATI
ON

Incomplete fractures
Complete fractures
2.3. Classification

 By number of fracture lines

 By number of fault lines
 Simple fractures
 Double fractures
 Triple fractures
 Comminutive fractures
 2.3. Classification

AFTER THE ANATOMICAL LOCALIZATION OF

THE FRACTURE LINE:
Fractures of the mandibular body
Fractures of the mandibular condyle
 Fractures of the coronoid process
2.4. Deplacement of
the fracture fragments
PRIMARY TRAVEL

high kinetic energy vulnerable

agent
 fractured
fragments exhibit primary
displacements resulting
from the strength and
direction of the trauma.
2.4. Displacement of fractured fragments

SECONDARY TRAVEL:
The active factor - the muscles
Passive factors:
Location
Direction of the fracture line
■ Dental status
2.5. Clinical aspects common to
mandibular fractures

Clinical signs of
Functional
disruption of bone
disorders
continuity

Clinical signs
associated with a
traumatic injury
2.6. Clinical aspects SPECIFIC to
the different locations of
mandibular fractures

1. MEDIAL FRACTURES
2.6. Clinical aspects SPECIFIC to
the different locations of
mandibular fractures

2.
PARAAMEDIAN
FRACTURES
(PARASYMPHYSI
S)
2.6. CLINICAL ASPECTS SPECIFIC TO THE
DIFFERENT LOCATIONS OF MANDIBULAR
FRACTURES

3. LATERAL FRACTURES
2.6. CLINICAL
ASPECTS
SPECIFIC TO
THE DIFFERENT
LOCATIONS OF
MANDIBULAR
FRACTURES
MANDIBULAR ANGLE
FRACTURES:
2.6. Clinical aspects SPECIFIC to the
different locations of mandibular
fractures

5. VERTICAL FRACTURES OF THE

MANDIBULAR BRANCH:
2.6. Clinical aspects SPECIFIC to the different locations of mandibular fractures

6.HORIZONTAL AND OBLIQUE FRACTURES OF THE

MANDIBULAR BRANCH:
2.6. CLINICAL
ASPECTS
SPECIFIC TO THE
DIFFERENT
LOCATIONS OF
MANDIBULAR
FRACTURES

SUBCONDYLAR
FRACTURES
(CONDILIAN PROCESS
FRACTURES)
 2.6. Clinical aspects SPECIFIC to the different
locations of mandibular fractures

HIGH SUBCONDILIAN FRACTURES

(FRACTURES OF THE CONDILIAN
NECK):
8.
 ELEVATED SUBCONDILIAN FRACTURES
(CONDILIAN NECK FRACTURES)

The relationship of the

small fragment with
the rest of the
mandible

The relationship between

the condyle head and the
glenoid fossa
2.6. CLINICAL ASPECTS SPECIFIC TO
THE DIFFERENT LOCATIONS OF
MANDIBULAR FRACTURES
FRACTURES OF THE CONDILIAN HEAD
(INTRACAPSULAR)
2.6. Clinical aspects SPECIFIC to
the different locations of mandibular
fractures

FRACTURES OF THE
CORONOID PROCESS:
Special types of mandible fractures

1. DOUBLE
PARAMEDIAN/LATERAL
FRACTURE:
 Special types of mandible fractures

2. MEDIAL/PARAMEDIAN FRACTURES ASSOCIATED WITH MANDIBULAR ANGLE FRACTURES

 Special types of mandible fractures

3. FRACTURES OF THE BODY / MANDIBULAR ANGLES ASSOCIATED WITH FRACTURES OF THE

OPPOSITE MANDIBULAR CONDYLE:
 Special types of mandible fractures

4. DOUBLE FRACTURES OF THE

MANDIBULAR ANGLE
 Special types of mandible fractures

5. DOUBLE FRACTURES OF THE MANDIBULAR CONDYLE:

Special types of mandible
fractures

6. COMINUTIVE FRACTURES
 Special types of mandible fractures

FRACTURES OF
THE ALVEOLAR
PROCESS:
 Special types of mandible fractures

EDENTATE MANDIBLE FRACTURES:

8.

Items 201, 237: Maxillofacial traumatology, Document creation date 2010-2011

© Francophone Virtual Medical University -
 Special types of mandible fractures

MANDIBLE FRACTURES
IN CHILDREN:
 2.7. Diagnosis of mandibular fractures

There is a comminutive fracture of the parasymphysed region of the

mandible with a fracture line that extends into the right canine (43) with an
obvious root fracture. There is a fracture through the branch of the right
mandible involving the base of the right coronoid process.
Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID:
56134
 2.8. The evolution of mandibular fractures

It can be of two types:

Primary consolidation under the conditions of a minimum
space between fragments
Primary consolidation under conditions of perfect bone
contact, with no minimum space between fragments
2.8. The evolution of mandibular
fractures

 SECONDARY HEALING:
The duration of the entire secondary healing process,
under the conditions of adequate treatment, is 4-6 weeks
in adults, 3-4 weeks in children
 2.8. The evolution of mandibular fractures

FACTORS INFLUENCING BONE

CONSOLIDATION:
The time elapsed between the trauma and the
application of the treatment
Type and accuracy of the treatment applied
 Factors related to the patient's condition: age,
nutritional status, certain general conditions
(endocrine diseases, degenerative diseases)
Complications

■ Immediate complications

■ Secondary complications
■
Complications

Septic risk
In the case of open fractures in the oral cavity, the risk of septic (abscess at the fracture focus,
osteitis, septic pseudarthrosis) is always possible. Usually, rapid therapeutic management and
the introduction of systematic antibiotic prophylaxis have made this risk rare.
Consolidation in vicious callus, skeleton malocclusion
Reduction techniques and stable osteosyntheses currently available routinely
have significantly minimized this risk.
Delayed consolidation and pseudarthrosis
■ And again, current osteosyntheses techniques have made this risk low.
SPECIAL ASPECT

Risk of damage to the upper airway

Association with intracranial and cervical spine lesions
Eye, nasal, otic or oral lesions require specific care
Risk of hemorrhage due to the rich vascularization of the territory
Specific lesions of the cranial nerves (V, VII)
Peculiarities regarding aesthetics and facial functionality
■ Lesions of the excretory ducts of the salivary or lacrimal glands can induce
complications and treatment difficulties
Special Aspect

Correct and complete evaluation of the polytraumatized patient – 25-33% of the deaths
caused by trauma can be prevented (Cales, Trunkey 1985)
Deaths – trimodal distribution – 3 maximum levels
I – first seconds/minutes after the trauma, by: brain, brainstem, cervical marrow, heart, aorta
or other large vessels
II – the first hours after the trauma – through CNS injuries or hemorrhages
■ III – on days/week after trauma – by sepsis, multiple organ failures, pulmonary
embolism
TREATMENT

The treatment is instituted according to:

~ severity of injuries
~ stability of vital signs
Scoring System

Glasgow Coma Scale – 1974, GrahamTeasdale; Bryan

Jannett
Quantify the severity of brain injuries
3 variables – motor response (CNS functionality), verbal
response (CNS ability to integrate information), eye
opening (TC activity)
Score 3-15
Letter T (tube) – intubated patient
GLASGO
W SCORE
 Trauma score/revised
trauma score

GCS TAS FR VALUE

13-15 >89 10-29 4

9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
Advanced Trauma Life Support

James Styner, 1978

- Rapid primary evaluation
- Resuscitation of vital functions
- Detailed secondary evaluation
- Initiation of the definitive treatment for each lesion
BASIC LIFE SUPPORT

■ Aim: The major objective of BLS is to maintain oxygenation in lungs, brain and heart with rescue
breathing and cardiac compression by which oxygen is transported to tissues before the ACLS.

■ Procedure: The three parts sequence [airway-breathing-circulation (ABC)].

Maintain:
 Airway
 Breathing
 Circulation
■ Each part of ABC begins with an assessment phase to determine patient’s response, presence of
pulse and state of respiration.
Airway
Breathing
CIRCULATION CHECK
Therapeutic principles in adults

■ Closed Reduction
Most of the mandibular fractures can be treated by closed
reduction. It is often advocated, because of its relative
simplicity, low cost and noninvasive nature of treatment.
A significant degree of displacement does not preclude the
use of a closed reduction to repair a mandibular fracture.
■ Open Reduction
Advantages of Open Reduction and Direct Fixation
Reduction and fixation is done under direct vision Stable
fixation is achieved by better approximation of fractured
fragments.
 Therapeutic principles in adults
● These are usually open fractures (in the oral cavity) including the
treatment is urgent, at best within hours of trauma.
● Patient left on an empty stomach until decision-making.
● Start of intravenous antibiotic prophylaxis.
1.In the event of a displaced fracture
Surgical treatment
Reduction and osteosynthesis by the open under general anesthesia
and nasotracheal intubation (to allow intraoperative control of the
dental joint.
Otherwise, orthopedic treatment
Mandibular-maxillary ("intermaxillary") blockage with steel wire
for six weeks, possibly achievable under local anesthesia.
IN CASE OF NON-DISPLACED FRACTURE
POSSIBILITY OF THERAPEUTIC
ABSTENTION (COOPERATING AND
MOTIVATED PATIENT); START-UP OF A
LIQUID DIET AND REGULAR
RADIOLOGICAL MONITORING FOR SIX
WEEKS.
1.In the event of a
displaced fracture
■ Intraoral route of highlighting the fracture for
osteosynthesis.
-if you can, is better to do intraoral osteosynthesis
because is more esthetic like that.
■ Cutaneous Route - An incision of 4-5 cm in the
submandibular region that interests the tegument,
subcutaneous cellular tissue, platysma muscle.
BONE PLATING IN
MANDIBULAR
FRACTURES
■ Advantages
Rigid or stable fixation
Obviates the need for immobilization of the mandible
Early return to home and work
Soft diet can be taken
Maintenance of oral hygiene
Useful in mentally challenged, physically handicapped patients
Maintenance of airway in multiple fractures.
Complications and management:

■ Suture dehiscence: It is found if the surgery for osteosynthesis is delayed due to some
reasons:
a. Timing of surgery
b. Due to inappropriate incision in the region of the attached gingiva, on 4th or 8th
postoperative day, the gap will be noticed. In such a case, the sutures are removed and
cleaning of the wound with 15% hydrogen peroxide is done. Frequent mouthwashes
are encouraged. Wound is allowed to heal with secondary intention.
■ Postoperative infection: This may be due to the following: Inadequate number of
screws applied ;Incorrect placement of the bone plates, outside the osteosynthesis lines;
Proximity of the plates to the apical region Inadvertent placement of the screws in the
teeth bearing area Lack of maintenance of oral hygiene postoperatively.
Complications and management:

■ Complications during primary treatment

■ Infection—Lowering the patient’s local or general resistance will predispose to infection.
■ Pathological fracture, debilitated patients, diabetics and patients on steroid therapy are more prone to
infection.
■ Nerve damage—Anesthesia of the lower lip due to neuropraxia or neurotmesis of the inferior alveolar
nerve is the most common complication. Facial nerve damage may be seen due to penetrating injuries.
■ Displaced teeth and foreign bodies— may be swallowed.
■ Chest radiograph should be done and if needed, bronchoscopy should be carried out. Foreign bodies
like glass pieces, fragments of teeth can get buried in the soft tissues of the lip. They should be
explored and removed.
■ Pulpitis Gingival and periodontal complications