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

Maxillofacial Trauma - Etiology and Incidence ► Multisystem injury 20-50% ► Nasal and mandibular fractures most common in community ED’s ► Midface and zygomatic injuries most common in Trauma centers ► 25% of women with facial trauma result of domestic violence ► Incidence of concomitant cervical spine injuries with facial fractures

Etiology and Incidence ► Older age, MVC and TBI-higher incidence ► Facial fractures-a distracting injury? ► Carotid artery injury ► Blindness may occur with facial fractures

Maxillofacial Trauma

Emergency Management and Resuscitation ► Airway  Most urgent complication-Airway compromise  Simple interventions first  No mandible? ► Intubation  Avoid nasotracheal intubation  May not want RSI ► Benzodiazepines ► Ketamine ► Etomidate  Be Prepared and Be Creative

Emergency Management and Resuscitation ► Airway Management Options  Awake intubation  Laryngeal Mask Airway  Fiberoptic intubation  Lateral or semi-prone position  Percutaneous transtracheal jet ventilation  Retrograde intubation  Cricothyroidotomy

Emergency Management and Resuscitation ► Hemorrhage Control  Rarely develop shock from facial bleeding alone  Direct Pressure  LeFort Fractures  Nasal hemorrhage may require A&P packing ► History  Vision  Teeth alignment  Abuse

Maxillofacial Trauma-Physical Exam ► Inspection  Facial elongation ► High grade LeFort Fracture  Asymmetry ► Deformities and cranial nerve injury ► Palpation  Tenderness  Step offs  Facial stability  Crepitus  Subcutaneous air  Cutaneous anesthesia

Maxillofacial Trauma-Physical Exam ► Periorbital and Orbital Exam  Perform early Professional Lid Retractor

Maxillofacial Trauma-Physical Exam ► Periorbital and Orbital Exam  Look for exophthalmos or enophthalmos  Pupil shape  Hyphema  Visual acuity  Entrapment signs  Raccoon sign ► Bimanual Palpation Test

Maxillofacial Trauma-Physical Exam ► Penetrating Injuries  Occult globe penetration  Eyelid lacerations ► Nose  Septal hematoma  CSF Rhinorrhea ► Ears  Subperichondral hematoma  Hemotympanum  Battle sign

Maxillofacial Trauma-Physical Exam ► Oral and Mandibular Exam  Mandible deviation  Teeth malocclusion  Paresthesia  Tongue Blade Test ► 95% Sensitive ► 65% Specific

Maxillofacial Trauma-Imaging ► Head, chest and abdominal trauma takes precedence ► PE detects up to 90% of fractures ► Plain Films ► CT  Orbital fractures  3D images available

Maxillofacial Trauma-Specific Fractures ► Frontal Sinus/Bone Fractures  Direct blow  Frequent intracranial injuries  Mucopyoceles  Consult with NS for treatment, disposition and antibiotics ► Nasoethmoidal-Orbital Injuries  Lacrimal apparatus disruption  Bimanual palpation if medial canthus pain  CT face

Maxillofacial Trauma-Specific Fractures ► Orbital Fractures  Usually through floor or medial wall  Enophthalmos  Anesthesia  Diplopia  Infraorbital stepoff deformity  Subcutaneous emphysema

Maxillofacial Trauma-Specific Fractures ► Orbital Fissure Syndrome  Fracture of the orbital canal ► Extraocular motor palsies and blindness ► If significant retrobulbar hemorrhage, may need cantholysis to save vision ► Zygomatic Fractures  Tripod fracture ► Most serious ► Lateral subconjunctival hemorrhage ► Need ORIF  Arch fracture ► Most common ► Outpatient repair

Tripod Fracture

Maxillofacial Trauma-Specific Fractures ► Maxillary Fractures  High-energy injury  100x gravity  Malocclusion  Facial lengthening  CSF rhinorrhea  Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial Fractures ► Mandibular Fractures  Second most common facial fracture  Often multiple  Malocclusion  Intraoral lacerations  Sublingual ecchymosis  Nerve injury  Plain films  Panorex  CT  Open Fractures ► Pen G or Cleocin

Body % Angle % Condyle % Symphysis 7-15 % Ramus 3-9 % Alveolar 2-4 % Coronoid Process 1-2 %

► 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 : ► ► 1- a crack of the enamel without loss of tooth structure. ► Do not require immediate treatment. ► 2-fracture of enamel only smoothing the sharp edge ► 2- fracture of enamel only smoothing the sharp edge ► regular vitality test, radiograph

► 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 : ► The treatment depends on many factors such 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 treatment is to maintain the vitality of the tooth.

► ► Class IV : ► ► Treatment usually involve removing the loose fragment. ► 1- tooth can be extruded orthodontically ► 2- crown lengthening to gain access to placement of restoration.

► Class v : ► 1) Horizontal Root fracture ► When the fracture occur near the apical 1/3, the prognosis is more favourable than the middle or 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, splinting the tooth ► 2)the tooth should be checked periodically for vitality and radiograph.

► (B) middle 1/3 root fracture : ► 1) reduction, splinting the tooth ► 2)the patient recall 2-3 months, checked the vitality,radiograph ► 3)if the tooth non vital and no healing the following treatment is performed: ► a) R C T of both fragments ► b) apical fragment removed surgically ► c) intraradicular pin to stabilize both segments

► (C) cervical 1/3 root fracture : ► ► 1)reductin, splinting the tooth ► 2)recall the patient periodically and checked the vitality and radiograph ► 3)if there is radiolucent and pulp necrosis the following treatment is performed ► a) extraction the tooth ► b) removed the apical fragment and endo-osseous implant placed ► c) orthodontic extrusion ► d) if the fracture is 1- 2mm infrabony remove the coronal segment and osteoplasty to expose the root

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

1) Lateral luxation : ► Displacement of the tooth in any direction other than the axial one ► If the patient comes immediately after trauma reposition, splinting ► Once the tooth have solidified in their position orthodontic treatment is required

1) Intrusion: ► Displacement the tooth into the socket A) primary tooth: A) primary tooth: will re-erupted over a period of few months. If the intruded tooth is in contact with underlying permanent tooth should be remove will re-erupted over a period of few months. If the intruded tooth is in contact with underlying permanent tooth should be remove B) permanent tooth: B) permanent tooth: ► a) immediate surgical repositioning, splinting ► b) orthodontic extrusion ► c) incomplete root formation the tooth will erupt spontaneously

2) Extrusion : ► Partially displacement the tooth out of the socket. A) primary tooth: Treatment usually extracted B) permanent tooth : ► reposition and splinting ► If the vitality of tooth is lost start root treatment immediately placing calcium ► hydroxide in the canal for 6-12 month followed permanent filling.

3) Avulsion: ► Complete displacement of the tooth from the socket. ► There are tow important factors to be consider in cases of avulsion ► 1)time between the injury and treatment ► 2)condition under which the tooth have been restored ► The tooth must be kept moist to prevent damage to the fibers of PDL

► Small fracture through the alveolar process. process. there may be concomitant injuries there may be concomitant injuries (crown, root fracture and soft tissue) managed by referral to an oral and maxillofacial surgery. (crown, root fracture and soft tissue) managed by referral to an oral and maxillofacial surgery. ► Treatment: redaction, splinting

Types of splinting : 1) acid_etched composite splinting 2) Interdental wiring 3) ( vacuum_formed plastic) splint 4) arch bare splint ► More rigid and the longer the stabilization, the more root resorption, ankylosis that can be expected.

Stabilization periods for dentoalveolar injury Duration of immobilization Duration of immobilization Dentoalveolar injury 7 _ 10 days 7 _ 10 days 1) Mobile tooth 2 _ 3 weeks 2 _ 3 weeks 2) Tooth displacement 2 _ 4 months 2 _ 4 months 3)Root fracture 7 _ 10 days 7 _ 10 days 4) Avulsion 4 _ 6 weeks 4 _ 6 weeks 5) Alveolar fracture