Professional Documents
Culture Documents
management
content:
initial assessment
anatomical consideration and displacement
dentoalveolar fracture
diagnosis and radiograph
principle of treatment
definitive treatment (soft tissue, mandible, dentoalveolar, midface fracture, upper
face fracture).
Complication of fracture
Initial assessment(1)(2)
The commonest causes of fractured jaws are fights, road accidents, falls and sport. frequently in the
mandible as in the maxilla.
Fractures may be direct, following a blow at the point where the break occurs, or may be indirect as
a result of a blow on the bone at some distance from where the lesion occurs.
They may be single, linear or comminuted compound. In the young, incomplete or greenstick
fractures of the mandible can occur.
clear of debris to reestablish the airway. To keep the tongue forward, a suture may be passed
through it, or the patient turned on his side, with control of the cervical spine.
Once an airway has been established, then the adequacy of ventilation must be assessed.
Early diagnosis of these potentially life-threatening conditions is essential so that they can be
managed and permit adequate ventilation of the patient.
Circulation
Reduction and fixation will often arrest haemorrhage because movement disturbs the natural arrest.
The pulse and blood pressure should be monitored to ensure that the patient does not become
shocked. "Q:What are clinical manifestation &management of shocked patient ?"
In the maxillofacial truama there is no excessive bleeding because there is no large vessels as in
the lower limbs to arrest the bleeding you can either :
N.B: in case of internal haemorrahge refer the patient to hospital & take ultrasound picture.
Disability(1)
Assessment of conscious state is commonly carried out using the Glasgow Coma Scale; which
records the patient's motor, verbal and eye movements in response to stimulation.
6_No movement
From the previous table Take the best score from each category to give a total coma score. And as
the score is decreased the problem is increased.
N.B: In addition to glassgow scale you should make rapid assessment for intercranial tension &
examination of vital signs.
1_Vomiting:vomiting is a good sign of increase intercranial tension after head trauma especially if
brain concussion is present.
2_Pupils:at first there is a sluggish reaction to light then it progress to no reaction and this stage
called (dilated fixed pupils).
All of the victim's clothing is removed to permit full assessment and exclude other injuries.
Pain
This can be severe particularly with comminuted and grossly displaced fractures, and should be
used but not Morphine or its derivatives because they may mask the signs of increasing intracranial
Pressure as will as its side effect(addiction) so Non-steroidal anti-inflammatory drugs may be
prescribed.
Mandible(4)
Muscles attaches to mandible are :
1. posteriorly
lateral ptregoid muscle to condyle
medial ptregoid muscle to medial surface of angle &ramus of mandible
massetar muscle to lateral surface of angle
temporalis muscle to coronoid process
It’s a very important to know the muscle action to determine direction of bone displacement and
the complication after the fracture (tongue close airway in bilateral body fracture) .
#The commonest sites of fracture in the mandible are the condyle neck, the angle and the canine
region. In the children the greenstick fracture usually occurs because the bone has more elasticity.
N.B: The angle of the mandible is a weak point because there is a change in the direction of the
grain of the bone which occurs where the vertical ascending ramus and horizontal body meet.
Further, the shape of the mandible in cross section changes as the thick lower border of the body
becomes thin at the angle specially if there is impacted eight .
Condylar fractures:(1)(4)
Codylar fracture can be due to direct trauma to condyle or indirect blow and the force transmit
through the bone to push the condyle against skull base & fracture occur.
In the unilateral condylar fracture the lateral pterygoid muscle draws the fractured head forward
medially and, the other muscles of mastication raise the ramus of the affected side to produce an
anterior open bite between the incisors and canines on the opposite side.
On opening the mouth the body of the mandible is displaced towards the affected side. with marked
deviation of the midline.
In bilateral condylar fractures both ascending rami are drawn up and back equally so that gagging
occurs on the posterior teeth causing an anterior open bite on both sides .
in occlusion
The intracapsular is more danger because it leading to intracapsular haematoma which changing to
granulation tissue then may lead to callus formation (ankylosis) .
The middle third is bounded below by the occlusal line of the maxillary teeth and above by a line
drawn through the pupils .
middle third of the face involve a complex of bones which include the paired bones, the maxilla,
palatine, zygomatic, nasal, lacrimal and inferior conchae, together with the single vomer and
ethmoid bones .
Fractures of the middle third of the face fall into six categories:
Alveolar
Guerin's/Le Fort I
Pyramidal/Le Fort II
Hieh transverse/Le Fort III
Naso-ethmoidacl omplex
Malar / zygomatic
I)Alveolar fractures :
These occur where the palate and alveolus are separated from the maxillary complex by a
transverse fracture just above the floor of the nose and the antrum .
The fracture line passes through the lateral and anterior walls of the maxillary sinuses and
continues up through the infraorbital margins to join across the bridge of the nose
The maxillary complex is virtually separated from the cranium by a fracture which traverses, the
lateral walls of both orbits and both orbital floors and crosses the midline at the root of the nose to
involve the cribriform plate of the ethmoid.
N.B: Lefort I fracture means fracture in the maxilla from base of the nose due to trauma , while lefort
I osteotomy means orthognathic surgery usually doing to correct class III faces.
Dento-alveolar fractures:(3)
Dento-alveolar fracture may be in tooth structure , periodontium or\& alveolar bone .
1) fracture In the enamel only without displacement "called crown fracture in fraction ,or
fracture in place".in this fracture there is enamel crack & no need for Treatment just do follow
up for vitality if non vital start RCT.
2) crown fracture reached to dentine but not pulp "called uncomplicated fracture".here doing
either rounding sharp angles or provide restoration.
3) crown fracture & reached to pulp "complicated fracture" .either RCT+selar+dentine bounding
agent then restoration , or Post &core treatment
4) fracture in cementum not involve the pulp "uncomplicated root fracture or root crown fracture
" .either Post & core , or RCT &restoration.
5) fracture in the cementum involving pulp "complicated root fracture".usually extraction.
6) fracture in root only "root fracture ".extraction but if in apical one third you can do
apicectomy.
B) Periodontium fracture(2)
In this case we also noting bleeding , damage , severe periodontium tear and
may be socket fracture and root resorption (either external or internal root resorption) .
4) Complete avulsion : The tooth is completely displaced from its socket . reimplantaion may be
done and fixed in its place by non rigid fixation (composite or arch wire).
N.B : Maximum time of periodontium vitality outside the mouth is 2 hours , except if put in a special
substances as milk (may increases the time to 6 hours),saline, saliva…or synthetic materials.
Fracture here either in one plate(lingual , buccal) or across the whole process(one plate or two
plates).
Treatment involves early reduction and stabilization of the involved segments. And depending
on the fracture’s severity, use either an open or closed technique.
Digital manipulation and pressure, along with rigid splint stabilization, will usually be sufficient in
the closed technique. Leave the splint in place for approximately 4 weeks.
A gross displacement and/or difficulty to reduction may necessitate the open technique. Inability
to freely reduce fracture segments may be due to root or bony interferences or impaction (apical
lock).
DIAGNOSIS OF FRACTURE(4)
To make correct diagnosis you should take appropriate history, examination and investigation .
History:
The time of the accident is important in assessing the urgency of treatment and the degree of
infection in compound fractures. The difficulty of reducing misplaced fractures increases as
healing is progresses. if patient is conscious ask about general condition and history of any
previous facial injury.(?)
The surgeon must consider all the possible tissues that might be involved in the trauma(skin,
,connective tissue blood vessels ,nerves, muscles , underlying bones, together with special
Structures such as the eyes and salivary gland). Examination are extraoral and intraoral :-
I) extraoral examination:
1-Frontal view :
By inspection: The patient is first looked at full face for obvious signs of injury
The surgeon then examines the eyes for damage, particularly depression, proptosis or a difference
in level.
The intercanthal distance should be measured from the midline. Any difference in the values on
either side or a marked increase from the normal range suggest as traumatic detachment of the
medial canthal ligaments.
upper half of the eye suggests bleeding from a fracture of the roof of the orbit.
The lower part of the conjunctiva suggests a fracture of the orbital floor.
Lateral only usually due to Zygomatico frontal suture.
All around suggests multiple orbital fracture.
Each eye is checked individually for vision and then both together for movement vertically and
horizontally (abducent nerve) and for double vision(diplopia) in all fields . Abnormalities of
movement and diplopia may be due to paralysis of the extrinsic muscles of the eye as a result of
cranial injury.
N.B: CSF contains glucose and this differentiate it from mucous discharge. if the CSF discharged
with blood we can detect it by observation of clotting, if no clotting occurs this may refer to presence
of CSF.
By Palpitation :
The surgeon move infront of the patient and uses the tips of his fingers to palpate and compare the
right and left sides,and to determine points of tenderness or breaks in the continuity of the facial
bones.
starts with the frontal bone then superior, lateral (zygomaticofrontal suture)and inferior margins of the
orbit and then proceeds to the bridge of the nose where any deviation from the midline or depression is
The fingers then move over the zygomatic arch to the temporomandibular joints and then The
patient is asked to open and close the mouth and perform lateral movements .
Fractures of the zygomatic arch may prevent opening as the coronoid process may jam against the
displaced zygomatic process.
In fractures of the condyle or Ascending ramus there is little movement of the condyle head on the
affected side or the mandible towards the opposite side.
When the joint is difficult to palpate the little finger may be put into the external auditory meatus and
the condyle felt through the anterior wall.
2_Lateral view :
this view used to ensures the frontal view. through this view we can see (nasal bone, chin, lateral
border of the mandible, and traumatic endophthalmus ).
This view from behind and above the head of patient when the patient is seating; From this view you
can evaluate and compare in both sides the following :
This view is inspection from down to above of the face; and used to see (Contour of zygomatic arch
and malar eminence)
Examine each eye separately for visual acuity , movement in different direction of the gaze
(cause of unilocular diplopia).
Then examine both eyes simultaneously for visual acuity movement of the eye in all directions
of the gaze, bilocular diplopia (cause of bilocular diplopia, vertical dystopia).
Examine of reated cranial nerve branches trigeminal (inferior alveolar, lingual, mental,
infraorbital ), abducent, facial nerve. (?)
A) Inspection :
B) Palpation :
The upper buccal sulcus is palpated for any sharp edges of bone or bruising diagnostic of a fracture
through the malar buttress.
Fractures of the maxillary alveolus or a midline split of the palate are detected by grasping the
alveolar segments and trying gently at first to move them by grasping the alveolus and the teeth in
one hand and trying to elicit movement, whilst the other hand palpates extraorally to determine the
level at which the fracture has occurred. The fingers are placed in turn over the root of the nose, at
the infraorbital margins and in the canine fossa.
Similarly the mandible is grasped in both hands, with the fingers over the occlusal surface of the
teeth and the thumbs under the lower border, and tested in segments for mobility.
The clinical findings should be written down and a provisional diagnosis made before radiographs
are ordered.
Radiographs
Radiographs are taken to establish the presence of fractures, the direction in which they run and the
amount by which they are displaced, and to identify radiopaque foreign bodies such as glass in the
soft tissues, Medico legally they are considered a diagnostic measure of the first importance, They
also provide a visual record of the progress of the patient.
Radiographs of all fractures must be taken in two planes .The following views usually give a
satisfactory survey of the facial bones :-
N.B:
2) Reduction of fracture
The best guide to accurate reduction is the occlusion of the teeth. In edentulous patients the
dentures are the only sound guide.
the fractured jaw is reduced to the sound jaw, but where many teeth are missing or both jaws badly
comminuted, the problem is more difficult. The surgeon must then rely more on anatomical
reduction of the bony margins, appearance of the patient.
Reduction should be done as soon as possible but where delay is unavoidable it should be
remembered that great difficulty will be experienced in reducing maxillary fractures after 10 days
and mandibular fractures after 3 weeks.
Monocortical bone screws placed between the roots of the canines and premolars in each quadrant
can allow IMF to be established during the operative procedure but will not withstand long periods of
immobilisation.
b) Eye let:
Eyelet wiring. (a) Making eyelet with two twists only of tails. (b) Tails of eyelet wire passed
between the teeth from buccal side. (c) Distal wire passed through the eyelet. (d) Left, shows
correct relationship of wire, flat against the tooth, for twisting. Right, inconect relationship. (e)
Intermaxillary wire passed from distal aspect of eyelets. (f) Intermaxillary wires tightened
c) Arch bur :
These may be more suitable where there are inconvenient gaps in the dental arch which make
eyelet wiring impossible.
Close fitting cast arch bars may be constructed from study models if time allows but preformed bars
are also available for immediate use.
Condylar fracture(2)(1)
Intra capsular >>>>>>>>>>> Extra capsular
The fractured condyle head is usually displaced forward and medially by the lateral pterygoid
muscle, while the muscles of mastication tend to draw the ascending ramus up and back to
produce an open bite, with rotation of the symphysis menti towards the affected side.
The patient should be told to stay on a soft diet and analgesic should be prescribed .Where
swelling and pain make this difficult, IMF may be applied or 1.-2 weeks using arch bars and
elastics to encourage the re-establishment of the occlusion.
In fracture dislocations the same treatment is adequate as it has been shown that, though
union occurs in an abnormal position, the head of the condyle remodels to make a functional
joint.
Fractures of the condyle not interfering with the occlusion are frequently managed
conservatively, that is with soft diet and regular review. A 2-week period of IMF rather than
ORIF is a common treatment choice if the occlusion is deranged. (2)
N.B:The management of bilateral condylar fractures is complicated due to an increased incidence of
anterior open bite and this does not always respond to a period of IMF.
Open reduction and internal fixation of at least one of the fractured condyles may be indicated if
these fractures lie outside the joint capsule.
This particularly applies in panfacial fractures where the special geometry of the face may be
difficult to reconstruct without this important dimension.
The close proximity of the facial nerve to the condylar neck makes the surgical approach
taxing and at present the application of IMF for 1-2 weeks is still advocated.
B. Orbital fractures
Fractures of the zygomatic complex will necessarily involve the orbit, but it is also possible to
sustain an isolated fracture of the orbit. This may tether the inferior rectus muscle, causing
diplopia, or be large enough to permit herniation of orbital fat and muscle into the maxillary
antrum. (2)
Such a 'blow-out' may be repaired with 'silastic' or titanium mesh materials or bone taken
from another site, for example iliac crest of the hip or the cranium. Exposure is achieved via
(infraorbital, blepharoplasty or transconjunctiva lncisions).The orbital roof and both walls may
also require exploration.
During operation avoid compression on the eye ball , which may lead to bradycardia that
might progress to cardiac arrest.
Retrobulbar haemorrhage(1)
This is a severe though rare hazard following reduction of zygomatic fractures or any intervention
involving the orbit. Bleeding behind the globe during or after the operation can cause proptosis ,pain
and decreasing visual acuity which, if the pressure is not relieved, may result in blindness .
The blood may be drained via an infraorbital or lateral canthal incision; however medical
management in the form of steroids, acetazolamide and mannitol can also be successful in
reducing the pressure on the optic nerve.
Postoperative eye observations every 15 minutes for 2 hours, then every 30 minutes for 2 hours will
aid in the early diagnosis and treatment of this condition.
Complicationso f fractures(2)(1)
1. Complications of facial soft tissue injury
• Scarring is inevitable but should be minimised by good surgical technique, including thorough
removal of any foreign body such as dirt, good wound apposition and evertion of wound margins.
• Scars may be thickened and result in functional deformity as well as an unacceptable cosmetic
appearance.where hypertrophic scars occur more commonly than keloids (extend beyond original
wound margins).
Primary teeth
• Grey discoloration of teeth after trauma suggests pulp death, while yellowing may suggest
calcification. At the earliest sign of pulpal death, the tooth should undergo root treatment or
extraction.
• Ankylosis is the fusion of the cementum to the surrounding alveolar bone. While its exact
pathogenesis is unknown, it occurs whenever periodontal tissue is lost and cementum/dentine come
into direct contact with the alveolar bone.
• An underlying developing permanent tooth may be damaged when primary teeth are involved in
trauma.
Permanent teeth
• Re-implanted teeth have a high incidence of developing external (surface) resorption. The
incidence is related to the length of time between avulsion and reimplantation. Internal
(inflammatory) resorption may also occur, although early removal of the pulp after injury can prevent
its development.
• Re-implanted teeth are also subject to ankylosis if not lost by external resorption.
Reference
1) PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY , FIFTH EDITION , EDITED BY U. J. MOORE
FDSRCS (ENG ), PHD (NCLE) LECTURER IN ORAL AND MAXILLOFACIAL SURGERY UNIVERSITY
OF NEWCASTLE-UPON-T YNE.
2) MASTER DENTISTRY ORAL AND MAXILLOFACIAL SURGERY, RADIOLOGY , PATHOLOGY AND
ORAL MEDICINE – BY DR PAUL COULTHARD, PROFESSOR KEITH HORNER, PROFESSOR PHILIP
SLOAN AND MS E LIZABETH D. T HEAKER .
3) PETERSON'S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY SECOND
EDITION MICHAEL MILORO E DITOR G. E. GHALI • P ETER E. LARSEN • PETER D. WAITE
ASSOCIATE EDITORS
4) LECTURE OF DR. EHAB HELMI FOR DENTAL STUDENT, FOURTH YEAR.