jaw-facial orthopedic. the aim, task. classification of jaws fractures. general characteristic of...

$: Jaw-facial orthopedic. The aim, task. Classification of jaws fractures. General characteristic of apparatus$
Jaw-facial orthopedic. Jaw-facial orthopedic. The aim, task. The aim, task.

Classification of jaws Classification of jaws fractures. General fractures. General characteristic of characteristic of

apparatus.apparatus.

Maxillofacial TraumaMaxillofacial Trauma - - Etiology Etiology and Incidence and Incidence

►Multisystem injury 20-50%Multisystem injury 20-50%►Nasal and mandibular fractures most Nasal and mandibular fractures most

common in community ED’scommon in community ED’s►Midface and zygomatic injuries most Midface and zygomatic injuries most

common in Trauma centerscommon in Trauma centers►25% of women with facial trauma 25% of women with facial trauma

result of domestic violenceresult of domestic violence► Incidence of concomitant cervical Incidence of concomitant cervical

spine injuries with facial fracturesspine injuries with facial fractures

Etiology and IncidenceEtiology and Incidence

►Older age, MVC and TBI-higher incidenceOlder age, MVC and TBI-higher incidence

►Facial fractures-a distracting injury?Facial fractures-a distracting injury?

►Carotid artery injuryCarotid artery injury

►Blindness may occur with facial fracturesBlindness may occur with facial fractures

Maxillofacial TraumaMaxillofacial Trauma

Emergency Management and Emergency Management and ResuscitationResuscitation

► AirwayAirway Most urgent complication-Airway compromiseMost urgent complication-Airway compromise Simple interventions firstSimple interventions first No mandible?No mandible?

► IntubationIntubation Avoid nasotracheal intubationAvoid nasotracheal intubation May not want RSIMay not want RSI

►BenzodiazepinesBenzodiazepines►KetamineKetamine►EtomidateEtomidate

Be Prepared and Be CreativeBe Prepared and Be Creative


►Airway Management OptionsAirway Management Options Awake intubationAwake intubation Laryngeal Mask AirwayLaryngeal Mask Airway Fiberoptic intubationFiberoptic intubation Lateral or semi-prone positionLateral or semi-prone position Percutaneous transtracheal jet ventilationPercutaneous transtracheal jet ventilation Retrograde intubationRetrograde intubation CricothyroidotomyCricothyroidotomy


►Hemorrhage ControlHemorrhage Control Rarely develop shock from facial bleeding Rarely develop shock from facial bleeding

alonealone Direct PressureDirect Pressure LeFort FracturesLeFort Fractures Nasal hemorrhage may require A&P packingNasal hemorrhage may require A&P packing

►HistoryHistory VisionVision Teeth alignmentTeeth alignment Abuse Abuse

Maxillofacial Trauma-Physical Maxillofacial Trauma-Physical ExamExam

► InspectionInspection Facial elongationFacial elongation

►High grade LeFort FractureHigh grade LeFort Fracture AsymmetryAsymmetry

►Deformities and cranial nerve injuryDeformities and cranial nerve injury

►PalpationPalpation TendernessTenderness Step offsStep offs Facial stabilityFacial stability

CrepitusCrepitus Subcutaneous airSubcutaneous air Cutaneous anesthesiaCutaneous anesthesia


► Periorbital and Periorbital and Orbital ExamOrbital Exam Perform earlyPerform early

Professional Lid Retractor


► Periorbital and Orbital ExamPeriorbital and Orbital Exam Look for exophthalmos or enophthalmosLook for exophthalmos or enophthalmos Pupil shapePupil shape HyphemaHyphema Visual acuityVisual acuity Entrapment signsEntrapment signs Raccoon signRaccoon sign

► Bimanual Palpation TestBimanual Palpation Test


►Penetrating InjuriesPenetrating Injuries Occult globe penetrationOccult globe penetration Eyelid lacerationsEyelid lacerations

►NoseNose Septal hematomaSeptal hematoma CSF RhinorrheaCSF Rhinorrhea

►EarsEars Subperichondral hematomaSubperichondral hematoma HemotympanumHemotympanum Battle signBattle sign


►Oral and Mandibular ExamOral and Mandibular Exam Mandible deviationMandible deviation Teeth malocclusionTeeth malocclusion ParesthesiaParesthesia Tongue Blade TestTongue Blade Test

►95% Sensitive95% Sensitive►65% Specific65% Specific

Maxillofacial Trauma-ImagingMaxillofacial Trauma-Imaging

►Head, chest and abdominal trauma Head, chest and abdominal trauma takes precedencetakes precedence

►PE detects up to 90% of fracturesPE detects up to 90% of fractures►Plain FilmsPlain Films►CTCT

Orbital fracturesOrbital fractures 3D images available3D images available

Maxillofacial Trauma-Specific Maxillofacial Trauma-Specific FracturesFractures

►Frontal Sinus/Bone FracturesFrontal Sinus/Bone Fractures Direct blowDirect blow Frequent intracranial injuriesFrequent intracranial injuries MucopyocelesMucopyoceles Consult with NS for treatment, disposition Consult with NS for treatment, disposition

and antibioticsand antibiotics►Nasoethmoidal-Orbital InjuriesNasoethmoidal-Orbital Injuries

Lacrimal apparatus disruptionLacrimal apparatus disruption Bimanual palpation if medial canthus painBimanual palpation if medial canthus pain CT faceCT face


►Orbital FracturesOrbital Fractures Usually through Usually through

floor or medial wallfloor or medial wall EnophthalmosEnophthalmos AnesthesiaAnesthesia DiplopiaDiplopia Infraorbital stepoff Infraorbital stepoff

deformitydeformity Subcutaneous Subcutaneous

emphysemaemphysema


► Orbital Fissure SyndromeOrbital Fissure Syndrome Fracture of the orbital canalFracture of the orbital canal

► Extraocular motor palsies and blindnessExtraocular motor palsies and blindness► If significant retrobulbar hemorrhage, may If significant retrobulbar hemorrhage, may

need cantholysis to save visionneed cantholysis to save vision

► Zygomatic FracturesZygomatic Fractures Tripod fractureTripod fracture

► Most seriousMost serious► Lateral subconjunctival hemorrhageLateral subconjunctival hemorrhage► Need ORIFNeed ORIF

Arch fractureArch fracture►Most commonMost common►Outpatient Outpatient

repairrepair

Tripod FractureTripod Fracture


►Maxillary FracturesMaxillary Fractures High-energy injuryHigh-energy injury 100x gravity100x gravity MalocclusionMalocclusion Facial lengtheningFacial lengthening CSF rhinorrheaCSF rhinorrhea Periorbital ecchymosisPeriorbital ecchymosis

LeFort FracturesLeFort Fractures

Maxillofacial Trauma-Specific Maxillofacial Trauma-Specific Facial FracturesFacial Fractures

►Mandibular FracturesMandibular Fractures Second most common facial Second most common facial

fracturefracture Often multipleOften multiple MalocclusionMalocclusion Intraoral lacerationsIntraoral lacerations Sublingual ecchymosisSublingual ecchymosis Nerve injuryNerve injury

Plain filmsPlain films PanorexPanorex CTCT

Open FracturesOpen Fractures►Pen G or CleocinPen G or Cleocin

BodyBody 30-40 %30-40 %

AngleAngle 25-30 %25-30 %

CondyleCondyle 15-17 %15-17 %

SymphysisSymphysis 7-15 %7-15 %

RamusRamus 3-9 %3-9 %

AlveolarAlveolar 2-4 %2-4 %

Coronoid Coronoid ProcessProcess

1-2 %1-2 %

► Ellis classification:Ellis classification:► Class I: ► crack or fracture of E only ► Class II: ► fracture of E , D with out pulp exposure ► Class III: ► fracture of E , D with pulp exposure ► Class IV:► Fracture line passes beneath the gingival margin► Class V:► Root fracture ► a) vertical b) horizontal

(apical , middle , cervical)

► Class I :Class I :

► 1- a crack of the enamel without loss of tooth structure.

► Do not require Do not require immediate treatment.immediate treatment.

► 2-2- fracture of enamel fracture of enamel only smoothing the only smoothing the sharp edge sharp edge

► regular vitality test , regular vitality test , radiographradiograph

► Class II :Class II :

► Immediate treatment of the crown is required to:

► 1) protect the pulp► 2) restore the esthetics and

function.

► Cover the expose of the dentine by a layer of calcium hydroxide to reparative dentine formation.

► A- Reattachment of tooth fragment.

► B- Acid-etch composite resin restoration

► Class III :Class III :

► The treatment depends The treatment depends on many factors such on many factors such as:as:

► 1) vitality of the exposed pulp.

► 2) Size of the exposure.► 3) Time elapsed since the

exposure.► 4) Degree of root

maturation.► 5) Restorability of the

fractured crown.

► The main objective of The main objective of treatment is to maintain treatment is to maintain the vitality of the tooth.the vitality of the tooth.

► Class IV :

► Treatment usually involve removing the loose fragment .

► 1- tooth can be 1- tooth can be extruded extruded orthodonticallyorthodontically

► 2- crown lengthening 2- crown lengthening to gain access to to gain access to placement of placement of restoration.restoration.

► Class v :Class v :► 1) Horizontal Root fracture1) Horizontal Root fracture

► When the fracture occur near When the fracture occur near the apical 1/3, the the apical 1/3, the prognosis is more prognosis is more favourable than the middle or favourable than the middle or cervical 1/3 because :cervical 1/3 because :

► 1) more alveolar support ► 2) immobilization of the

tooth is much easier

► Treatment of root fracture depends upon :

► 1) Condition of the pulp ► 2) amount of mobility or

the level of the fracture line

► (A) apical 1/3 root fracture

► 1) reduction , 1) reduction , splinting the tooth splinting the tooth

► 2)the tooth should 2)the tooth should be checked be checked periodically for periodically for vitality and vitality and radiograph.radiograph.

► (B) middle 1/3 root (B) middle 1/3 root fracture :fracture :

► 1) reduction , splinting 1) reduction , splinting the tooth the tooth

► 2)the patient recall 2-3 2)the patient recall 2-3 months , checked the months , checked the vitality ,radiographvitality ,radiograph

► 3)if the tooth non vital 3)if the tooth non vital and no healing the and no healing the following treatment is following treatment is performed:performed:

► a) R C T of both a) R C T of both fragments fragments

► b) apical fragment b) apical fragment removed removed surgically surgically

► c) intraradicular pin to c) intraradicular pin to stabilize both stabilize both segmentssegments

► (C) cervical 1/3 root fracture (C) cervical 1/3 root fracture ::

► ► 1)reductin , splinting the 1)reductin , splinting the

tooth tooth ► 2)recall the patient 2)recall the patient

periodically and checked the periodically and checked the vitality and radiographvitality and radiograph

► 3)if there is radiolucent and 3)if there is radiolucent and pulp necrosis the following pulp necrosis the following treatment is performed treatment is performed

► a) extraction the a) extraction the tooth tooth

► b) removed the apical b) removed the apical fragment and fragment and endo-osseous implant endo-osseous implant placed placed

► c) orthodontic c) orthodontic extrusionextrusion

► d) if the fracture is 1-d) if the fracture is 1-2mm infrabony 2mm infrabony remove the coronal remove the coronal segment and segment and osteoplasty to expose the osteoplasty to expose the rootroot

►1) lateral luxation 1) lateral luxation ►2) intrusive luxation 2) intrusive luxation ►3) extrusive luxation 3) extrusive luxation ►4) avulsion 4) avulsion

1) Lateral luxation1) Lateral luxation : :

►Displacement of the Displacement of the tooth in any direction tooth in any direction other than the axial one other than the axial one

► If the patient comes If the patient comes immediately after trauma immediately after trauma reposition, splintingreposition, splinting

►Once the tooth have Once the tooth have solidified in their position solidified in their position orthodontic treatment is orthodontic treatment is requiredrequired

1) Intrusion:1) Intrusion: ► Displacement the tooth into Displacement the tooth into

the socket the socket

A) primary tooth:A) primary tooth: will re-erupted over a period of will re-erupted over a period of

few months. If the intruded few months. If the intruded tooth is in contact with tooth is in contact with underlying permanent tooth underlying permanent tooth should be remove should be remove

B) permanent tooth:B) permanent tooth: ► a) immediate surgical a) immediate surgical

repositioning , repositioning , splinting splinting

► b) orthodontic extrusion b) orthodontic extrusion ► c) incomplete root c) incomplete root

formation the tooth will formation the tooth will erupt spontaneouslyerupt spontaneously

2) Extrusion :2) Extrusion :

► Partially displacement Partially displacement the tooth out of the the tooth out of the socket .socket .

A) primary tooth:A) primary tooth: Treatment usually Treatment usually extracted extracted

B) permanent tooth :B) permanent tooth :► reposition and splinting reposition and splinting ► If the vitality of tooth is If the vitality of tooth is

lost start root treatment lost start root treatment immediately placing immediately placing calcium calcium

► hydroxide in the canal hydroxide in the canal for 6-12 month followed for 6-12 month followed permanent filling.permanent filling.

3) Avulsion:3) Avulsion:► Complete displacement Complete displacement

of the tooth from the of the tooth from the socket .socket .

► There are tow important There are tow important factors to be consider in factors to be consider in cases of avulsion cases of avulsion

► 1)1)timetime between the injury between the injury and treatment and treatment

► 2)2)conditioncondition under which under which the tooth have been the tooth have been restored restored

► The tooth must be kept The tooth must be kept moist to prevent moist to prevent damage to the fibers of damage to the fibers of PDLPDL

► Small fracture Small fracture through the alveolar through the alveolar

process. process. there may be concomitant there may be concomitant

injuriesinjuries (crown, root fracture and (crown, root fracture and

soft tissue) managed by soft tissue) managed by referral to an oral and referral to an oral and maxillofacial surgery .maxillofacial surgery .

► Treatment: redaction , Treatment: redaction , splintingsplinting

Types of splinting :Types of splinting :

1) acid_etched composite splinting 1) acid_etched composite splinting 2) Interdental wiring 2) Interdental wiring 3) ( vacuum_formed plastic) splint 3) ( vacuum_formed plastic) splint 4) arch bare splint 4) arch bare splint

►More rigid and the longer the More rigid and the longer the stabilization, the more root resorption stabilization, the more root resorption , ankylosis that can be expected ., ankylosis that can be expected .

Stabilization periods for dentoalveolar Stabilization periods for dentoalveolar injuryinjury

Duration of Duration of immobilization immobilization

Dentoalveolar injuryDentoalveolar injury

7 _ 10 days7 _ 10 days 1) Mobile tooth1) Mobile tooth

2 _ 3 weeks2 _ 3 weeks 2) Tooth 2) Tooth displacement displacement

2 _ 4 months 2 _ 4 months 3)Root fracture 3)Root fracture

7 _ 10 days7 _ 10 days 4) Avulsion 4) Avulsion

4 _ 6 weeks4 _ 6 weeks 5) Alveolar fracture 5) Alveolar fracture

jaw-facial orthopedic. the aim, task. classification of jaws fractures. general characteristic of...

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