Treatment principles of maxillofacial trauma

Reporter : Ho-Tai Wu

Evaluation of p’t with facial traumaClassification of facial fracturesTreatment of facial fractures

Maxillofacial Injuries

• Treatment divided into following phasesEmergency or initial care

Early careDefinitive care

Trauma

ER

OMFS,ENT,Plastic

Emergency Care

• Preserve the airway

• Control of hemorrhage

• Prevent or control shock

• C-Spine stabilization

• Control of life-threatening injurieshead injuries, chest injuries, compound

limb fractures, intra-abdominal bleeding

Emergency Care

Preserve the airwayExistence & identification of obstructionManually clear of fractured teeth, blood

clots, denturesEndotracheal intubation & packing of

oronasal airway

Emergency Care

Control of hemorrhage• Extensive vascularity of head & neck

may lead to massive blood lossMonitor vital signs closelyIntravenous infusion

• Penetrating injuries need to be exploredArteriogramEsophagram

Emergency Care

Prevent or control shock Hemorrhage most common

cause of shock after injury Multiple injury patients have

hypovolemia Goal is to restore organ

perfusion

Emergency Care

C-Spine stabilizationAvoid any movement of spinal

columnUntil rule out C-spine Fx

Lateral C-spine radiographsCT of C-spineNeurologic exam

Early Care

Emergency care has stabilized patientInitial stabilization of fracturesDebridement & dressing of soft tissuesElective tracheostomyPhysical exam & historyLaboratory testsComplete head & neck examination

Diagnosis of maxillofacial injuries

History

Patient, witness or family member How did the accident occur ? When did the accident occur ? What are the specifics of the injury ? Was there a loss of consciousness ? What symptoms are now ?

Physical examination

• InspectionHemorrhageOtorrheaRhinorrheaContour deformityEcchymosisEdemaContinuity defectsMalocclusion

Physical examination

• PALPATION“Step” DefectCrepitus

Bony segmentsSubcutaneous

emphysemaMobility

Physical examination

• Neurological examination Visual or pupillary changes (CN II III IV VI) Abnormalities of ocular movements (neurologic,

orbital area fractures ) Motor function of the facial muscle (CN VII) Muscles of mastication (CN V) Sensation the facial area (CN V)

Maxilla Mobility of the maxilla either as

an isolated zygoma or nasal bones

Palpated for step deformites in forehead, orbital rim, nasal or zygoma areas

Evaluation of the nose, nasal spetum and paranasal structures

Intercanthal distance (naso-orbital ethmoid injures)

Mandible TMJ Occlusion plane Laceration of oral cavity Mobility and missing of the

teeth

DIAGNOSTIC IMAGING

Mandible fractures :

PA view

Lateral oblique view

Towne’s view

Panoramic view

Occlusal view

CT

DIAGNOSTIC IMAGING

Midface fractures Water’s viewLateral skull viewPA skull view Submental vertex viewCT scans3-D reconstruction

3D CT

Evaluation of p’t with facial traumaClassification of facial fracturesTreatment of facial fractures

Mandibular Fractures

• 50% of mandibular fractures are multipleExamine patient and

radiographs closely and suspect additional fractures

Mandibular Fractures

Condylar AngleBodySymphysealAlveolarRamusCoronoid precess

Mandibular Fractures

Greenstick Simple

Comminuted Compound

Mandibular Fractures

Horizontally favorable Horizontally unfavorableVertically favorableVertically unfavorable

Mandibular Fractures• Radiographic evaluation

Midface Fractures

• Three buttresses allow face to absorb forceNasomaxillary

(medial) buttressZymaticomaxillary

(lateral) buttressPyterigomaxillary

(posterior) buttress

Midface Fractures• LeFort I Transverse Maxillary• Lefort II Pyramidal• Lefort III Craniofacial Dysjunction• Zygomatic Complex• Naso-orbital/Ethmoid

Occlusion involved

Lefort I FractureTransverse Maxillary

Lefort II FracturePyramidal

Lefort III FractureCraniofacial Dysjunction

above the level of teeth

at level of nasal bones

at orbital level

(Rene’ Lefort, 1901)

Naso-orbital/Ethmoid Zygomatic Complex

Evaluation of p’t with facial traumaClassification of facial fracturesTreatment of facial fractures

Goals of the treatments

1. Rapid bone healing

2. Return of normal appearance

3. Masticatory and nasal function

4. Restoration of speech

5. Acceptable esthetic

Basic surgical principle

1. Reduction of the fracture

2. Fixation of the bony segment

3. Stabilization of the bony segment

4. Immobilization of segments

5.5. Preoperative occlusionPreoperative occlusion must be restored

6.6. InfectionInfection in the area must be eradicated

Basic surgical procedure

1. Place the teeth in the proper occlusion

2. Appropriated reduction of bony fractures

3. Bony repair should also precede soft tissue repair

4. Fractures treated as soon as the p’t condition permits

5. Rigid fixation begins in the area where fractures can e most easily stabilized .

Principle of mandibular fracture Closed reduction 1. IMF ( Prefabricated arch bar )

2. Ivy loop wiring

3. Continuous loop wiring

4. Heavy elastic traction (pull the bony segments)

5. Circummandibular wiring (edentulous p’t)

6. Lingual or occlusal splint (children)

Principle of mandibular fracture

Open reduction• Continued displacement of the bony segments • Unfavorable fracture (angle fracture)

Intraosseous wiring + IMF (3 to 8 weeks) Rigid internal fixation these method use bone

plates, bone screws or both to fix the fracture. Proper occlusal established before reduction

stabilization and fixation of the bony segment

Advantages of rigid fixation

1. IMF is eliminated or reduced

2. Improved postoperative nutrition

3. Improved postoperative hygiene

External skeletal fixation

1. Appearance and inconvenience

2. Functional movement

3. Comminuted fracture

Principle of midface fracture

1. Zygomaticomaxillary buttress

2. Zygomaticofrontal area

3. Orbital rim area

Principle of midface fracture

• Occlusion related (Le fort fractures)Rehabilitation of occlusion relationshipReduction of bone segmentStablization of fractured segments

Principle of midface fracture

Stablization of fractured segments Direct Intraosseous wiring Suspension wiring techniqueBone plate & screws

Principle of midface fracture

• Zygomatic Complex & Naso-orbital- Ethmoid fracture

Repair functions of eye, nose & mastication. Acceptable esthetic Prevent interfere to coronoid process

(Zygomatic arch)

Goals of the treatments 1. Rapid bone healing

2. Return of normal appearance

3. Masticatory and nasal function

4. Restoration of speech

5. Acceptable esthetic

Conclusion

Thanks for your attention !!!

END