Controversies in Maxillofacial TraumaControversies in

MODERATOR – DR . RA JASEKHAR G .

PRESENTED BY-DR . SHEETAL KAPSE

INCLUSIONS

• INTRODUCTION

• CURRENT

• CONTROVERSIES

• CONCLUSION

• REFERENCES

1. Management of Fractures Through the Angle of the Mandible

2. Management of Condylar Process Fractures3. Management of Comminuted Fractures of the Mandible4. Management of Atrophic Mandible Fractures5. Management of Mandibular Fractures in Children6. Management of Nasal Fractures7. Management of Orbital Fractures8. Management of Naso-Orbital-Ethmoidal Fractures9. Management of Frontal Sinus Fractures10. Fixation of zygomaticomaxillary complex11. Sequencing of fixation in case of pan facial trauma12. Management of Parotid Gland and Duct Injuries13. Use of Prophylactic Antibiotics in Preventing Infection of

Traumatic Injuries

INTRODUCTION

• Controversy can be defined as a dispute, generally with a right and a

wrong side of the argument.

• Controversy can also be defined as a discussion marked by the expression

of opposing

• When there are different approaches to surgical management, it is often not

a matter of right or wrong, but rather what the surgeon believes gives the

best results views.

1. Management of Fractures Through the Angle of the Mandible

A. Does the angle

fracture have to

extend through the

Goinal Angle of

mandible ??

B. Inclusion of different

type of fractures in

the same series.

• Anatomic region• Start of fracture line

• Anterior to gonion• Vertically and posteriorly• To the gonion• Slightly above it• anteriorly

C. Tension & compression zones change

with different biting position and

fracture lines.

D. Use of antibiotics

E. Timing of treatment

F. Teeth in the fracture line

Ellis - 85% contained a third molar. Spiessl- lists three undesirable effects of extracting

an unerupted tooth in the line of an angle fracture : The possibility of converting a closed fracture to an

open one Loss of the bony buttress on the tension side

(superior surface) Loss of the possibility for inserting a tension band

plateEllis E. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg 2002;60: 863–5.

Soriano E, Kankou V, Morand B, et al. Fractures of the mandibular angle: factors predictive of infectious complications. Rev Stomatol Chir Maxillofac 2005; 106:146–8.

Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal fixation of the mandible. Berlin: Springer-Verlag; 1989. p. 199.No difference in the rate of infection

with closed reduction

Presence of a third molar associated with a fracture through the angle of the mandible increases the risk of infection irrespective of whether or not the tooth is erupted or impacted, or whether or not the tooth is removed during surgery.

D. Use of antibiotics

E. Timing of treatment

F. Teeth in the fracture line

G. Close versus open reduction

Even when the fracture is not displaced, open treatment is usually provided so that internal fixationdevices can be placed to maintain the alignment of the fragments and obviate postoperative MMF.

Only indication of MMF

H. Internal fixation schemes Wire fixation + weeks of MMFOther fixation device without MMF

Bicortical screws & one large and one small bone plate, or two small plates

Good stability, infection

Bending/ torsional forces

Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal fixation of the mandible. Berlin: Springer-Verlag; 1989. p. 199.

Champy M, Lodde JH, Must D, et al. Mandibular osteosynthesis by miniature screwed plates via buccal approach. J Maxillofac Surg 1978;6:14–9.

Levy FE, Smith RW, Odland RM, et al. Monocortical miniplate fixation of mandibular fractures. Arch Otolaryngol Head Neck Surg 1991;117:149–54.

Alkan A, Celebi N, Ozden B, et al. Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral MedOral Pathol Oral Radiol Endod 2007;104:752–6.

Ellis E, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. J Oral Maxillofac Surg 1994;52:1032–6.

H. Internal fixation schemes

I. Postoperative care

• Force distribution through soft tissues explains why a single miniplate can be very successful in the management of fracture through the angle.

• Association with co-existing fractures of mandible• Comminuted angle fractures

Rudderman RH, Mullen RL, Phillips JH, et al. The biophysics of mandibular fractures: an evolution toward understanding. Plast Reconstr Surg 2008; 121:596–607.

requirement of additional

fixation

AntibioticsMouth wash & oral hygiene

Gap at the inferior borderUse of elastics

2. Management of Condylar Process Fractures

Parameters Closed reduction

(3-6 weeks for adults & 10-14 days for children)

Open reduction

MIO (maximum interincisal opening) Equal or more Faster rate of recovery

Movements Clinically acceptable Faster rate of recovery

Occlusion Chances of malocclusion More satisfactory result

Facial contour No difference No difference

Chin deviation No difference - deviation Less incidences

Post treatment TMJ / masticatory muscle pain Frequent pain Less incidences

Procedure related complications In particular medical situations Present

Laskin D M. Management of Condylar Process Fractures. Oral Maxillofacial Surg Clin N Am 21 (2009) 193–196.

Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89–98.

DEGREE OF DISLOCATION & ANGLE OF DISPLACEMENTS

Mandibular condyle fractures evaluation of the Strasbourg Osteosynthesis Research Group classification

EDWARD ELLIS III – Symposium on condylar fractures 2004

• ABSOLUTE INDICATIONS- Displacement into the middle cranial fossa/external auditory meatus- Inability to obtain occlusion by non surgical/closed method- Invasion by foreign body- Lateral extra capsular displacement

• RELATIVE INDICATIONS - Bilateral fractures in edentulous jaws- IMF contraindicated for medical reasons- Bilateral fractures associated with comminuted midface fractures- Severe periodontal problems & loss of teeth- patients desire to avoid IMF

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

• The problem with most comparative studies that have

been reported is that they are generally retrospective

rather than prospective and that there is considerable

variation in the patient selection and outcome criteria

used as well as in the follow-up time.

• Therefore, until better-designed comparative studies

are available that will allow evidence-based decisions to

be made, one can only look at individual case series for

some guidance.

3. Management of Comminuted Fractures of the Mandible

• 5-7 % of all mandibular fractures, usually compound type.

Joe Hall Morris appliance for comminuted fracture of the symphysis

Traditional conservative management

MMF + external fixator Long healing period Restricted function Morbidity

MMF

Roger Anderson appliance controlling multiple comminuted mandibular fractures.

Indications

Significant head injury

Necessary equipments are not available

OPEN REDUCTION AND INTERNAL FIXATION

• Load bearing reconstruction plate• Decreases healing time• Post op MMF is not required• No scarring of skin• Good functional out come

Technical points• Stabilize the teeth and alveolus with arch bars• Intact lingual periosteum• Simplification of fracture

Technical points• Reconstruction plate with 3-4 screws on

either side of fractures• Defect closure with bone graft

4. Management of Atrophic Mandible Fractures

Closed reduction techniques for atrophic edentulous mandible fractures

1. Gunning splints with arch bars2. Circummandibular wiring of oblique fractures

3. External fixatorAnterior and posterior pin connected by a transverse bar spanning the fracture

4. No treatment / soft diet

A. Indications

B. Approaches (intraoral - vestibular/

extraoral)

Open reduction and internal fixation techniques for atrophic edentulous mandible fractures

C. Fixation with

Reconstruction plate Locking / non-locking minplates

Titanium or other mesh crib with

autografts

Lag screw

Alloplastic materials –

• Hydroxyapatite,

• Tricalcium phosphate,

• Glass ceramics,

• Glass carbonate

• Injectable calcium phosphate cements

Future materials –

• Gene therapy

• Tissue engineering

5. Management of Mandibular Fractures in Children

1. Diagnosis – because of child co-operation

2. Fracture pattern & displacement of segments

3. Open versus closed reduction and closed functional treatment

4. Duration of MMF

5. Role of other treatment modalities

6. Titanium, stainless steel or bioresorbable materials for fixation

Hiu GA, Prabhu IS, Morton ME, et al. Acrylated stainless steel basket splint for mandibular fractures in children. Br JOralMaxillofacSurg 2012;50:577–8.

The occlusion was satisfactory, without infection or malocclusion. None required revision, and there was no deviation of the mandible, ankylosis, or disturbances of growth.

Five children with mandibular fractures were treated with a split acrylic splint, which secured the fracture by wiring around the mandible.

6. Management of Nasal Fractures

1. TIMING OF NASAL FRACTURE

TREATMENT

• If a patient is seen shortly after trauma,

before significant edema develops

• Lacerations with exposure of the underlying

skeletal or cartilaginous elements

• Presence of a septal hematoma

• Within the first 10 days of injury are less likely to require a revision

septorhinoplasty

2. Local v/s general anesthesia

• In the presence of minor nasal bony deviation and no

associated septal or nasal tip displacement, closed reduction

under local anesthesia has been suggested as the first line of

treatment.

• Complex or severely displaced fractures may require treatment under general anesthesia.

3. OPEN V/s CLOSED TECHNIQUES

• Closed reductions - most acute isolated nasal fractures with minimal bony and

septal injury (within 10 days).

• Internal packing for 3 days & external for 7 to 10 days.

• 14% to 50% cases - Postreduction deformities - secondary rhinoplasty.• The final decision - condition of the septum and the need to preserve the

connection between the septum, upper lateral cartilages, and nasal bones.

Denver splint.

Outcomes of nasal fracture treatment may be compromised by the fact that late morphologic changes can occur over 1 or more years because of scarring.

7. Management of Orbital Fractures

1. INDICATION FOR SURGICAL REPAIR OF ORBIT

Lack of ocular motility

Diplopia : Surgery may increase the risk of diplopia, at least temporarily.

Enophthalmos : define this as greater than 1 cm3 & greater than 2.0 mm typically indicates the need for surgical

Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthalmos by computer-based volume measurement of orbital fractures in a Korean population. Ophthal Plast Reconstr Surg 2008;1:36–9.

• There seems to be a direct relationship between the increase of orbital volume and measured enophthalmos.

a. Volume increase of < 1 mL, enophthalmos ~ 0.9 mm, b. Volume 2.3 mL ~ 2 mm.

# For every 1 mL increase of volume there is approximately a 0.9 mm increase in enophthalmos.

# However, in normal orbits, there can be a natural volume difference of up to 8% between the left and right sides.

2. TIMING OF ORBITAL SURGERY

Dortzbach and later Leitch and coworkers : surgery for orbital floor fractures within 14 and 21 days after trauma.

Cole and coworkers : gave indications for immediate repair

i. Trumatic optic neuropathy (alteration in visual acuity & color desaturation test)ii. Occulocardiac reflexiii. Penetrating injuriesiv. Age – younger patients

3. USE OF STEROIDS : Corticosteroids can be used as the only treatment if the visual acuity is better than 20/400

Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg 2007;120:57–61.

Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 983;90(9):1066–70. Leitch RJ, Burke JP, Strachan IM. Orbital blowout fractures: the influence of age on surgical outcome. Acta Ophthalmol 1990;68:118–24.

4. MATERIALS FOR RECONSTRUCTION

Potter JK, Malmquist M, Ellis E III. Biomaterials for Reconstruction of the Internal Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):609–627.

Abbreviations: FF, very favorable; F, favorable; U, unfavorable; UU, very unfavorable.

Abbreviations: BAG, bioactive glass; FF, very favorable; F, favorable; HA, hydroxyapatite; PDS, polydioxanone; PGA, polyglycolide; PLA/PGA, polylactide/polyglycolide; PLDLA, poly L/D lactide copolymer; PLLA, poly L lactide; Sil, silicone; Tef, Teflon; Tit, titanium; U, unfavorable; UU, very unfavorable.

8. Management of Naso-Orbital-Ethmoidal Fractures

• NOE fractures rarely occur as isolated events.

1. Extent of fracture : NOE fractures associated

with panfacial injuries are associated with a

diffuse facial edema, whereas isolated NOE

fractures are associated with localized ecchymosis

and edema in the nasal and periorbital regions.

2. Requirement of treatment : examination of

canthus containing fragments and telecantus

3. Early versus late management : waiting no more than 2 weeks.4. Closed versus open reduction : indications, approaches, fixation5. Position of reattachment of medial canthus

9. Management of Frontal Sinus Fractures

Repair Obliteration (ablation) Cranialization

Preservation of the sinus anatomy, including the nasofrontal duct, sinus

mucosa, and its anterior and posterior bony walls

Obliteration involves the elimination of the frontal

sinus cavity while maintaining the anterior and

posterior tables

similar to frontal sinus obliteration with the exception that the posterior table is

completely removed

No treatment

• Volume of material needed is highly variable, averaging approximately 35 to 40 cm3 to as much as 200 cm3

Endoscopic-Assisted Repair

10. Fixation of zygomaticomaxillary complex

Rodrigo Otávio Moreira Marinho, Belini Freire-Maia. Management of Fractures of the Zygomaticomaxillary Complex. Oral Maxillofacial Surg Clin N Am 25 (2013) 617–636.

Zingg M et al Classification of ZMC fractures. (A) Type A1: isolated zygomatic arch fracture. (B) Type A2: lateral orbital wall fracture. (C) Type A3: infraorbital rim fracture. (D) Type B: complete monofragment zygomatic fracture. (E) Type C: multifragment zygomatic fracture.

Judgement of fracture reduction

1. Zygomaticosphenoid suture

2. Zygomaticomaxillary buttress

3. Infraorbital rim

4. Frontozygomatic suture

Priority of fixation

1. Zygomaticomaxillary buttress

2. Frontozygomatic suture

3. Infraorbital rim

4. Zygomatic arch

Sequence of fixation

1. Frontozygomatic suture

2. Infraorbital rim

3. Zygomaticomaxillary buttress

4. Zygomatic arch

11. Sequencing of fixation in case of pan facial trauma

Classical approaches

“bottom up and inside out”“top down and outside in”Booth PW, Eppley BL, Schmelzeisen R, editors.

Maxillofacial trauma and esthetic facial reconstruction. Philadelphia: Saunders; 2012.

“bottom up and inside out”

top down and outside in

12. Management of Parotid Gland and Duct Injuries

1. DIAGNOSIS : Use of dye - excessive extravasation from the lacerated duct may complicate surgery.Saline can be injected if difficulty is encountered in finding the proximal end. No fluid seen in the wound indicates that the duct is intact.

2. TIMING OF REPAIR : Done early, preferably in the first 24 hours.• Late complications, such as a parotid fistula, are difficult to treat.

3. WOUND CLOSURES WITHOUT DUCT REPAIR

# MANAGEMENT OF INJURIES TO THE GLAND AND DUCT

• Repair of the injury, putting a stent in the duct, and placing a pressure dressing, botox in chronic cases.

• Injury to the duct - repair of the duct over a stent, ligation of the duct, or fistulization of the duct into the oral cavity.

• Injury of the duct orifice - insertion of a drain.

4. Leaving the stent in place after duct repair – subsequent swelling can cause obstruction of duct

5. Use of an autogenous graft for repair of continuity defect of duct

14. Use of Prophylactic Antibiotics in Preventing Infection of Traumatic Injuries

1. PROPHYLACTIC ANTIBIOTICS IN PATIENTS WITH SKIN WOUNDS

• According to the principles of presurgical prophylaxis, antibiotics, if they are to be given at all, should be administered as soon as possible after the injury, if possible within the first 3 hours and continued for 3 to 5 days.

• Staphylococcus aureus and streptococci : Cloxacillin and first-generation cephalosporins

1. Open joints or fractures 2. Human or animal bites3. Intraoral lacerations4. Heavily contaminated wounds

(eg, those involving soil, feces, saliva or other contaminants).

5. Patients who have prosthetic devices and at risk for developing endocarditis.

6. Systemic antibiotics also are recommended when there is a lapse of more than 3 hours since injury,

7. Lymphedematous tissue involvement,

8. Host is immunocompromised.

INDICATIONS

2. USE OF PROPHYLACTIC ANTIBIOTICS FOR PREVENTION OF INFECTION OF INTRAORAL WOUNDS

• ‘‘through-and-through’’ lacerations - a course of prophylactic antibiotics to prevent infection after these wounds are repaired.

3. TOPICAL ANTIBIOTICS FOR TREATMENT OF TRAUMATIC WOUNDS

• Ointments - bacitracin, neomycin, or polymyxin have been routinely used.

4. ANTIBIOTIC PROPHYLAXIS IN PATIENTS WITH OPEN FRACTURES AND JOINT WOUNDS

• Classification Of Open Fractures And Joint

Type of Description Involved pathogens

Empirical antibiotics

IIs an open fracture with a skin wound that is clean and less than 1 cm long

S aureus, streptococci

Spp, and aerobic gram-negative

bacilli

First- or second-generation

Cephalosporin

within 6 hours + 24 hours postop

II

An open fracture with a lacerationThat is more than 1 cm long, but without evidence of extensive soft tissue damage, flaps, or avulsion

III

An open segmental fracture orAn open fracture with extensive soft tissue damage or a traumatic amputation

Certain environmental exposures

More no. Of gram negative

Organisms

Clostridium, Acinetobacter, Pseudomonas,

Clostridium, Aeromonas, Pseudomonas,

Aeromonas, Vibrio

Cephalosporin & aminoglycoside

Penicillin

within 6 hours + 24 hours postop

Why there is controversy ??i. clinical studies fail to demonstrate a lower infection

rate among patients with uncomplicated wounds treated with prophylactic antibiotics

ii. studies have assessed their efficacy after suture wound closure

CONCLUSION

• In the treatment of many kinds of traumatic injuries of the

Maxillofacial region, too few randomized, controlled

studies are available to supply strong supporting evidence

for definitely selecting one surgical technique or procedure

over another. Therefore, we have to rely upon expert

opinion, as well as the literature, to guide us in the

decision-making process.

REFERENCES

1. Oral Maxillofacial Surg Clin N Am 21 (2009). doi:10.1016/j.coms.2009.01.001

2. Jiewen Dai, Guofang Shen, Hao Yuan, Wenbin Zhang, Shunyao Shen, Jun Shi. Titanium Mesh Shaping and Fixation for the Treatment of Comminuted Mandibular Fractures. J Oral Maxillofac Surg 74:337.e1-337.e11, 2016.

3. Booth PW, Eppley BL, Schmelzeisen R, editors. Maxillofacial trauma and esthetic facial reconstruction. Philadelphia: Saunders; 2012.

4. William Curtis, Bruce B. Horswell. Oral Maxillofacial Surg Clin N Am 25 (2013) 649–660.