Treatment principles of maxillofacial traumaReporter : Ho-Tai Wu

Evaluation of pt with facial traumaClassification of facial fracturesTreatment of facial fractures

Maxillofacial InjuriesTreatment divided into following phasesEmergency or initial care

Early careDefinitive care

TraumaEROMFS,ENT,Plastic

Emergency CarePreserve the airwayControl of hemorrhagePrevent or control shockC-Spine stabilizationControl of life-threatening injurieshead injuries, chest injuries, compound limb fractures, intra-abdominal bleeding

Emergency CarePreserve the airwayExistence & identification of obstructionManually clear of fractured teeth, blood clots, denturesEndotracheal intubation & packing of oronasal airway

Emergency CareControl of hemorrhageExtensive vascularity of head & neck may lead to massive blood lossMonitor vital signs closelyIntravenous infusionPenetrating injuries need to be exploredArteriogramEsophagram

Emergency CarePrevent or control shockHemorrhage most common cause of shock after injuryMultiple injury patients have hypovolemiaGoal is to restore organ perfusion

Emergency CareC-Spine stabilizationAvoid any movement of spinal columnUntil rule out C-spine FxLateral C-spine radiographsCT of C-spineNeurologic exam

Early CareEmergency care has stabilized patientInitial stabilization of fracturesDebridement & dressing of soft tissuesElective tracheostomyPhysical exam & historyLaboratory testsComplete head & neck examinationDiagnosis of maxillofacial injuries

HistoryPatient, witness or family memberHow 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 examinationInspection

HemorrhageOtorrheaRhinorrheaContour deformityEcchymosisEdemaContinuity defectsMalocclusion

Physical examinationPALPATIONStep DefectCrepitusBony segmentsSubcutaneous emphysemaMobility

Physical examinationNeurological 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 TMJOcclusion planeLaceration of oral cavityMobility and missing of the teeth

DIAGNOSTIC IMAGINGMandible fractures : PA viewLateral oblique view Townes view Panoramic viewOcclusal viewCT

DIAGNOSTIC IMAGINGMidface fractures Waters viewLateral skull viewPA skull view Submental vertex viewCT scans3-D reconstruction

3D CT

Evaluation of pt 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 FracturesCondylar AngleBodySymphysealAlveolarRamusCoronoid precess

Mandibular Fractures

GreenstickSimpleComminutedCompound

Mandibular FracturesHorizontally favorable Horizontally unfavorableVertically favorableVertically unfavorable

Mandibular Fractures Radiographic evaluation

Midface FracturesThree buttresses allow face to absorb forceNasomaxillary (medial) buttressZymaticomaxillary (lateral) buttressPyterigomaxillary (posterior) buttress

Midface FracturesLeFort I Transverse MaxillaryLefort II PyramidalLefort III Craniofacial DysjunctionZygomatic ComplexNaso-orbital/Ethmoid Occlusion involved

Lefort I FractureTransverse Maxillary

Lefort II FracturePyramidalLefort III FractureCraniofacial Dysjunctionabove the level of teethat level of nasal bonesat orbital level(Rene Lefort, 1901)

Naso-orbital/EthmoidZygomatic Complex

Evaluation of pt with facial traumaClassification of facial fracturesTreatment of facial fractures

Goals of the treatments Rapid bone healingReturn of normal appearanceMasticatory and nasal functionRestoration of speechAcceptable esthetic

Basic surgical principleReduction of the fractureFixation of the bony segmentStabilization of the bony segmentImmobilization of segmentsPreoperative occlusion must be restoredInfection in the area must be eradicated

Basic surgical procedure1. Place the teeth in the proper occlusion2. Appropriated reduction of bony fractures3. Bony repair should also precede soft tissue repair4. Fractures treated as soon as the pt condition permits5. Rigid fixation begins in the area where fractures can e most easily stabilized .

Principle of mandibular fractureClosed reduction 1. IMF ( Prefabricated arch bar )2. Ivy loop wiring3. Continuous loop wiring4. Heavy elastic traction (pull the bony segments)5. Circummandibular wiring (edentulous pt)6. Lingual or occlusal splint (children)

Principle of mandibular fracture Open reductionContinued 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

IMF is eliminated or reducedImproved postoperative nutritionImproved postoperative hygieneExternal skeletal fixation

Appearance and inconvenienceFunctional movementComminuted fracture

Principle of midface fractureZygomaticomaxillary buttressZygomaticofrontal area Orbital rim area

Principle of midface fractureOcclusion related (Le fort fractures)Rehabilitation of occlusion relationshipReduction of bone segmentStablization of fractured segments

Principle of midface fractureStablization of fractured segments Direct Intraosseous wiring Suspension wiring techniqueBone plate & screws

Principle of midface fractureZygomatic Complex & Naso-orbital- Ethmoid fractureRepair functions of eye, nose & mastication.Acceptable estheticPrevent interfere to coronoid process (Zygomatic arch)

Goals of the treatments Rapid bone healingReturn of normal appearanceMasticatory and nasal functionRestoration of speechAcceptable estheticConclusion

Thanks for your attention !!!END