maxillofacial trauma - iraqi hard tissue society · maxillofacial trauma waseem jerjes. size of the...
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Maxillofacial Trauma
Waseem Jerjes
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Size of the problem
• Total no facial injuries = 500,000
– 832 per 100,000 population– 340,000 male– 160,000 female– 140,000 are serious injuries
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Causes
• Falls 40%• Interpersonal violence 34%• Sports / other 21%• RTA 5%
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General principles (remember)
• Primary and secondary survey
• Reconstruction of soft tissues
• Accurate diagnosis• Early surgery (14 days)• Expose all bony fragments• Rigid fixation (IMF, ORIF)• Immediate bone grafting
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Look
– Hemorrhage– Otorrhea– Rhinorrhea– Contour deformity– Ecchymosis– Edema– Continuity defects– Malocclusion
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Radiographical Investigations
• OPG, PA Mandible (lower third #s)• OM 0, 15, 30 (Middle third #s)• CT (upper third #)
• CT, MRI can be always requested when indicated
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Soft tissue injuries of the oral & maxillofacial region
• Skin (minimal debridement)-Nylon 5-6/0
• Muscles+SC tissue-Vicryl 4/0
• Intraoral lacerations-Vicryl 3-4/0
• Small vessels ligation-Vicryl 3/0
• Big vessels ligation-4/0 Prolene
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Soft tissue injuries of the oral & maxillofacial region
• Facial nerveEpineural suturing or reapproximation of the ends-
high success rate
• Parotid ductSuspect injury if weakness of the buccal branches
of the facial nerve identifiedExamine the duct opening (stimulate, probe),
repair over thin stentSalivary collections and fistulas, stenosis and
parotitis
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Soft tissue injuries of the oral & maxillofacial region
• Lacrimal apparatus Canaliculi, lacrimal sac or duct-repair over
thin silastic stent-insert along the length of the lacrimal system
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Hard tissue injuries of the oral & maxillofacial region
• Immediate management • Airway and cervical spine controlStabilization with hard collarRemove vomits, blood, broken teeth and
denturesChin lift, jaw thrust or reduce mid face #Intubation, cricothyroidotomy, tracheostomy
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Cervical spine
• High risk groups• Mandible - C1 C2 #• Midface - C5 C6 #
• Assume present
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Hard tissue injuries of the oral & maxillofacial region
• BreathingAdequate ventilation and exclude co-existing chest
injury
• Circulation and control bleedingCannulae, infusion, bloods, transfusion Manual reduction of fractures (orthodontic and K
wires) and nasal packing can reduce bleedingPacking and facial bandaging External carotid ligation (behind ramus, maxillary
sinus)
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Associated injuries
Ophthalmic assessment10% of patients with facial fractures have
associated eye injuries 10% of patients with major facial fractures
have cervical spine injuries
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Mandibular fractures
• Symptoms and signsPain, trismus, malocclusion, crepitus,
bruising (oral/facial), step (mandible border/dentition), paraesthesia (IAN, LN, MN), haematoma
• Locations: condyle, body, angle, symphysis, parasymphysis, alveolus, coronoid process
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Mandibular fractures• Common patternsAngle + contralateral bodyParasymphysis and contralateral condyleGuardsman
Deviation on opening-toward the side of the mandibular condyle fracture
Favourable or unfavourable (muscle action)
Radiological investigations (OPG, PA mandible)
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Mandibular fractures• Conservative management-unilateral
condyle, symphysis, undisplaced #s• ORIF-monocortical or bicotical screws1 plate (Champy’s-muscles), 2 plates• IMF (arch bars+wires)-condyle. Bilateral
condyles?IMF 3-6weeks, oral hygiene, feeding,
breathing• External fixation (extensive defects,
osteomyelitis)
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No displacement>30o Medial rotation>5mm bone overlapLoss of bone contact
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Zygomatic fractures• Occurs in a tetrapod fashion Zygomatic process (ZF suture)Greater wing of sphenoid MaxillaTemporal bone (arch)
• Symptoms and singsBruising and swelling (oral/facial), malar
depression, step deformity, subconjunctival haematoma, trismus (coronoid)
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Zygomatic fractures
• Symptoms and singsEpistaxis (lining maxillary sinus),
paraesthesia (ION), enophthalmos, dystopia (lateral, vertical or both), diplopia (tethering), reduced visual acuity (retinal detachment)
• Radiological investigations (OM 0, 15, 30), then CT (orbital floor/blow out/panfacial)
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Zygomatic fractures
• Locations Undisplaced fracturesIsolated arch fractureUnrotated body fractureBody fracture with medial rotation (ZF)Body fracture with lateral rotation (ZF)Complex fracture (lateral maxillary wall)Associated with orbital floor fracture
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Zygomatic fractures
• ManagementConservativeGillies’ liftORIF over 1-3 sites
(ZF, infraorbital rim, lateral maxillary wall)
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Maxillary fractures• Le Fort fractures (often asymmetrical)I (Geurin): the “floating palate” fracture Contains alveolus, palate, pterygoid platesII: the “pyramidal” fracture Contains bulk of maxilla, lacrimal crests, piriform
margin, alveolus, palateIII: “craniofacial dysjunction”Contains: detachment of midfacial skeleton from
cranial base
Saggital fractures and dentoalveolar
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Maxillary fractures• Symptoms and signs Bruising and swelling (oral/facial),
haematoma, Battle’s sign, malocclusion, epistaxis, enophthalmos, diplopiam paraesthesia (ION), step deformity
Dish-face appearance (displacement) Movement of segments can differentiate
Radiological investigations: OM? CT? 3D-CT
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Levels of Maxillary Fractures
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Maxillary fractures
• ManagementConservative (non-union)ORIF (bone grafting)
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Orbital fractures
• Occurs with:1. Zygomatic fractures2. Nasoethnoidal fractures3. High Le Fort fractures• Isolated fractures-pressure applied to
globe• Orbit fracture at weakest point-
inferomedial floor-paper layer fracture
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Orbital fractures
• Symptoms and signsBruising and swelling, subconjunctival
haematoma, periorbital haematoma, step deformity, enophthalmos, diplopia
Radiological investigations: PA skull, OM (tear drop sign, fluid level), CT
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Orbital trauma
Penetrating injuryVisual acuityOcular movements
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Orbital fractures
• ManagementConservative SurgeryAutologous tissue (split calvarial bone graft,
rib, iliac crest, superficial segment of anterior maxilla)
Alloplastic material (titanium-mesh, Gore- Tex, Silicone, Medpor wafers)
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Nasal Fractures• Most commonly fractured nasal bone• Lateral impact-deviation of nasal septum and
bones• Frontal impact-collapse of the nasal dorsum,
splaying of the nasal bones, dislocation of the septum
• Plane 1: disruption of the cartilagenous cartilage. Plane 2: disruption of the bony septum and nasal bones. Plane 3: involve the piriform aperture and medial orbital rim (mild NE #)
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Nasal Fractures• Symptoms and signsBruising and swelling, obvious deformityCheck for septal haematoma-pressure-septum
necrosis• Radiological investigations: PA and lateral skull • ManagementConservativeRelocate the nasal septum and nasal bones
followed by packing and splintingSecondary rhinoplasty
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Nasoethmoidal fractures
• Caused by trauma to the interorbital region
• Occurs with ethmoidal sinus, medial orbital wall, root of nose #s
• Symptoms and signsBruising and swelling, step deformity,
telecanthus (medial canthal tendon), enophthalmos, diplopia
Radiological investigations: CT
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Nasoethmoidal fractures
• ManagementConservativeORIF Nasal bones elevation and nasomaxillary buttress
reconstructionMedial canthal tendon: plating, transnasal fixation
Lacrimal system, no exploration, injuries settle within 6 weeks
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Frontal sinus fracture
• Symptoms and signsDepression or laceration over the supraorbital
ridge, glabella, or lower forehead, bony defectMay be associated with NOE complex and midface
(nasofrontal duct)CSF rhinorrhea-posterior table frontal sinuscan result in cosmetic deformity and mucocele
formationRadiological investigations: CT
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Anterior wall Posterior wall
Combined anterior + posterior wall
Classification of frontal sinus fractures
or
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Frontal sinus fracture• ManagementConservativeORIF of the anterior wallSinus obliteration and ORIF of anterior wall
(damage drainage system)Cranialization (CSF leak)Cranialization with dural repair
• Complications: meningitis, cerebral abscesses, mucoceles, osteitis
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High resolution CT scans required
Note: Combined anterior/posterior and posterior wall fractures will almost certainly involve the duct
Obstruction of drainage
Chronic sinusitis
Mucopyocele
Osteomyelitis
Brain abscess
Possible result of blocked fronto-nasal duct
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Retrobulbar Haemorrhage
• Bleeding into non yielding space, the orbit, cause an increased orbital pressure
• This causes impaired venous outflow and increased intraoccular pressure and decreased perfusion
• Resulting in ischaemia and retinal infarction and blindness
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Retrobulbar haemorrhage
PainProptosisLoss of visual acuity
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Retrobulbar Haemorrhage
• Diagnosis is important, 90 minutes to correct vascular insult or irreversible damage results.
• TreatmentMedicalMassage eye redistribution of extraoccular fluidSit patient up & sedateMannitol 20% 2g/kg iv over 4 minutes monitor
U&Es repeat 6 to 8 hourlyAcetazolamide 500mg iv (delayed effect)
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Retrobulbar Haemorrhage• TreatmentMedicalMegadose corticosteroids 3-4 mg/kg
dexamethasone sodium phosphate followed by 1-3 mg/kg 6 hourly for 5 to 7 days (reduces secondary injury)
Papaverine (smooth muscle relaxant) 30-60 mg iv slowly over 1 to 2 minutes can be repeated 3hrly
If no improvement after 20 to 30 minutes surgical decompression is indicated
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Retrobulbar Haemorrhage
• Treatment SurgicalIf post-operative and orbital septum violated
simple remove all suturesLateral canthotomy with or without
cantholysisTransantral ethmoidectomy (Lynch)
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Summary
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Thank you