Maxillo-facial Trauma

Diagnosis of maxillofacial trauma

1. History

2. Clinical examination

3. Radiographic examination

• general Signs and symptoms of mandibular fractures.

• Occlusal changes

• Deviation on opening

• Altered range of motion

• Localized pain

• Lacerations, ecchymosis, or hematoma

• Neurosensory deficits of the inferior alveolar nerve

• Changes in facial contour or mandibular arch form

• Blood in external auditory canal

• Mobility of bone segments/palpable step-offs

• general Signs and symptoms of mandibular fractures.

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• general Signs and symptoms of mandibular fractures.

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• general Signs and symptoms of mandibular fractures.

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•Lateral oblique radiograph.

•Postero-anterior radiograph .

•Occlusal radiograph.

•Panoramic radiograph.

•C.T. scan

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occlusal radiograph of a mandibular parasymphasis fracture

lateral oblique (body, ramus, angle, coronoid process)

Panoramic radiographs remain the gold standard for mandible fracture screening.

Panoramic radiographs are tomograms where the mandible is in the focal trough and show a flat image of the mandible. Because the curve of the mandible appears in a 2-dimensional image, fractures are easier to spot leading to an accuracy similar to CT except in the condyle region. In addition, broken, missing or malaligned teeth can often be appreciated on a panormic image which is frequently lost in plain films. Medial/lateral displacement of the fracture segments and especially the condyle are difficult to gauge so the view is sometimes augmented with plain film radiography or computed tomography for more complex mandible fractures.

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Computed

tomography is the

most sensitive and

specific of the imaging

techniques. The facial

bones can be visualized as

slices through the skeletal

in either the axial, coronal

or sagittal planes

Computed tomography

Coronal view

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3-dimensional CT view\ 3D reconstruction, however, can mask smaller fractures owing to volume averaging, scatter artifact and surrounding structures simply blocking the view of underlying areas.

•Fracture management

General principle

Treatment protocol

1-Reduction

2-Fixation&Immobilization

Treatment of Maxillofacial

fractures

A- Reduction

I- Closed

2-Opened

B- Fixation

Indirect Intermaxillary

fixation & splints

direct Rigid and non-rigid

Fixation

&

&

&

Closed Reduction

•A closed reduction takes place when the

fracture site is not surgically exposed but the reduction

is estimated accurate by palpation of the bony

fragments and by restoration of the functioning

segments through intermaxillary fixation (IMF)

• 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. The presence of teeth provides an accurate guide for reduction. Teeth may on occasion be brought into contact during reduction, yet be occluding incorrectly owing to lingual inclination of the fractured fragments. Whenever the occlusion is used as an index accurate reduction, it is important to recognize any pre existing occlusal abnormalities, such as anterior open bite, etc. Wear facets on the teeth, can provide valuable clues to previous contact areas

Indications:

• 1. Nondisplaced favorable fracture.

• 2. Severely atrophic edentulous mandible.

• 3- Grossly comminuted fractures.

• 4. Lack of soft tissue overlying the fracture site.

• 5. Fractures in children with developing teeth buds.

• 6. Coronoid process fractures.

Contraindications: of Closed Reduction

– 1-Medical conditions that should avoid intermaxillary fixation

(IMF)

A. Seizure disorder

B. Mental retardation

C. Nutritional concerns

D. Respiratory diseases (COPD)

– 2- Unfavorable fractures

Closed reduction & Indirect fixation:

Means of fixation

1. indirect inter dental wiring. (Ivy loop)

2. Arch bars.

3. Gunning-type splints.

4. labiolingual splints

5. External Pin fixation.

MMF or IMF

Maxillomandibular fixation (MMF) was previously defined to as

intermaxillary fixation IMF)

MMF is obtained by applying wires or elastic bands between

the upper and lower jaws, to which suitable anchoring devices

can be attached,

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one or two Ivy loops are placed in each quadrant, with traction then placed between the jaws in each quadrant.

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Arch Bars

MMF with Erich arch bar

Arch Bars Many types of prefabricated arch bars are available. But the most popular one and commonly used is the Erich‘s arch bar. It is a prefabricated arch bar with hooks incorporated on the outer surface with flat malleable stainless steel metal strip. It provides an effective, quick and inexpensive method of fixation. The bar is available in spool form. The bar should be cut accurately to the length of the dental arch. Accuracy in this regard will prevent injury to the adjacent soft tissues by protruding ends. Each arch bar is to be fixed to the upper and lower dental arches. On the upper jaw, the hooks are arranged in an upward direction. The bar is attached to the lower jaw with the hooks in a downward direction.

The arch bar should be adapted to the buccal surface of each arch by giving a shape of the arch by bending it. Bending of the arch bar should start at the buccal side of the last tooth progressing past the midline and finishing at the other end. The arch bar is fixed to each tooth, with 26 gauge stainless steel wire, which is passed from the mesial surface of a tooth to the lingual side and back on the buccal side from the distal surface of the tooth. One end of the wire is above the bar and the other below. By twisting the two ends of wire together, the bar is attached securely and firmly to the necks of the teeth on the buccal surface of the arch. The twisting of the wires should be always done in a clockwise manner, so that later on removal of wires can be done in anticlockwise manner. Improper adaptation of the bar, ligation of an insufficient number of teeth and inefficient tightening will result in inadequate stability of the arch bar. Advantages of the arch bar include less trauma because of the thin wire and greater stability in an arch, even if some teeth are missing, because the edentulous gaps can be spanned by this rigid appliance. In case of displaced mandibular body fractures, the arch bar can be divided and placed on either side of the fracture line. Elastic traction will reduce the fracture and bring it into normal occlusion. Then the elastics can be replaced by wiring.

IMF screws when the occlusion is reliable

Edentulous mandibular fractures: there is special challenge in treating these fractures:

i. Alveolar resorption is four times greater in the mandible than in the maxilla.

ii. Inferior alveolar vascular supply to the bone is greatly compromised.

iii. Too little cancellous bone for repair (osteoblastic endosteum).

iv. Normal healing potential is retarded.

v. Open reduction amounts to stripping of periosteum, which impairs osteogenesis, as

there is greater dependence on periosteal supply in atrophic mandible.

However, small bone discrepancies (nonanatomic alignment by closed reduction) are

usually of no consequences by maturation of the bone.

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Bone awl for gunning splint fixation

Circumpalatal wiring procedure for fitting the Gunning splint to the maxillary edentulous ridge

Gunning splint

Length of MMF:

• adults 4 -6 weeks.

• children 1- 3 weeks.

• elderly patients 6-8 weeks.

external pin fixation: Indications for external pin fixation:

1.Comminuted fracture.

2.Continuity defects. (gun shot injury)

3.Pathological fractures.

4.Infected fractures. (osteomeylitis)

5.Bone grafting procedure

6.Atrophic edentulous mandible.