2.  Dentists serve as officers in the military to provide preventative and specialty dental care to soldiers and their families. Dental careers are available in many specialty areas including orthodontics, oral surgery and pediatrics. Dentists on active duty receive special pay in addition to their officer basic pay.

4.  Short Description Dental care is one of the health services provided to all military personnel. It is available in military dental clinics all over the world. Dental specialists assist military dentists in examining and treating patients. They also help manage dental offices.

5.  What They Do Dental specialists in the military perform some or all of the following duties: Help dentists perform oral surgery  Prepare for patient examinations by selecting and arranging instruments and medications  Help dentists during examinations by preparing dental compounds and operating dental equipment

6.  Clean patients’ teeth using scaling and polishing instruments and equipment Operate dental X-ray equipment and process X-rays of patients’ teeth, gums, and jaws Provide guidance to patients on daily care of their teeth Perform administrative duties, such as scheduling office visits, keeping patient records, and ordering dental supplies

8.  Helpful Attributes Helpful school subjects include biology and chemistry. Helpful attributes include: Ability to follow spoken instructions and detailed procedures  Good eye-hand coordination  Interest in working with people

9.  Training Provided Job training consists of classroom instruction, including practice in dental care tasks. Further training occurs on the job and through advanced courses. Course content typically includes: Preventive dentistry  Radiology (X-ray) techniques  Dental office procedures  Dental hygiene procedures

11.  Work Environment Dental specialists in the military usually work indoors in dental offices or clinics. Some specialists may be assigned to duty aboard ships.

12.  Civilian Counterparts Civilian dental specialists work in dental offices or clinics. Their work is similar to work in the military. They typically specialize in assisting dentists to treat patients, provide clerical support (dental assistants), or clean teeth (dental hygienists).

14.  Emergency management  Facial exam  Fractures  Major  Minor  Soft tissue injuries  Unusual injuries

15.  Acute  Airway compromise  Exsanguination  Associated intracranial or cervical-spine injury  Delayed  Meningitis  Oropharyngeal infections

16.  Estimated 3,000,000 facial trauma cases per year in USA  Estimated 40 to 50% of motor vehicle victims have facial injury  No uniform reporting or registry of cases

17.  Respiratory  upper airway  Visual  Olfactory  Mastication  Cosmetic  Communication  Individual recognition

18.  Airway control / immobilize cervical spine  Bleeding control  Complete the primary survey  Secondary survey  Consider NG or OG tube placement

19.  Plain radiographs if fractures suspected  CT if suspect complex fractures

20.  Repair soft tissue immediately if no other injuries  Delay soft tissue repair until patient in OR if surgery for other injuries necessary

21. Step 1: Airway control  Oxygen for all patients  May need to keep patient sitting or prone  Stabilize C-spine early  Large bore (Yankauer) suction available

22. Step 1: Airway control  Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed  Combitube®, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate

23. Step 2 : Bleeding control  Can be major threat to life  Use universal precautions  Direct pressure dressings initially  Contraindicated: blind vessel clamping

24. Step 2 : Bleeding control  Rapid nasal packing may be necessary  Be sure blood is not just running down posterior pharynx

25. Step 2 : Bleeding control  Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination  Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury

26.  Blood in airway  “Debris” in airway  Vomitus, avulsed tissue, teeth or dentures, foreign bodies  Pharyngeal or retropharyngeal tissue swelling  Posterior tongue displacement from mandible fractures

27. Scalp  Check for lacerations, hematomas, stepoffs, tenderness  Bleeding maybe brisk until sutured  Can use stapler for rapid closure

28. Ears  Examine pinnae, canal walls, tympanic membranes  Suction gently under direct vision if blood in canal  Put drop of canal fluid on filter paper for “ring sign”  CSF leak  Assess hearing

29. Eyes  Pupils, anterior chamber, fundi, extraocular movements  Conjunctivae for foreign bodies  Palpate orbital rims  No globe palpation if suspect penetration

30. Eyes  Lid injury can leave cornea exposed  Use artificial tears or cellulose gel

31. Overall facial appearance  Assess for symmetry, deformity, discoloration, nasal alignment  Palpate forehead & malar areas

32. Nose  Check septum for hematoma & position  Check airflow in both nares  Palpate nasal bridge for crepitus  Check fluid on filter paper for “ring sign” (for CSF leak)

33. Mouth  Check occlusion  Reflect upper & lower lips  Check Stenson's duct for blood  Palpate along mandibular and maxillary teeth (be careful !)

34. Mouth  Palpate along exterior of mandible  Pull forward on maxillary teeth

35. Neurologic  Skin fold symmetry at rest  Motor: each division of CN-VII  Sensation: 3 divisions of CN-V  Sensation on tongue  Gag reflex

36. Major  Lefort I, II, III  Mandibular Minor  Nasal  Sinus wall  Zygomatic  Orbital floor  Antral wall  Alveolar ridge

37.  Nasal fracture  30 g  Zygoma fractures  50 g  Mandibular (angle) fractures  70 g  Frontal region fractures  80 g  Maxillary (midline) fractures  100 g  Mandibular (midline) fractures  100 g  Supraorbital rim fractures  200 g

38.  Lefort fractures can coexist with additional facial fractures  Patient may have different Lefort type fracture on each side of the face

39. Pull forward on maxillary teeth  Lefort I: maxilla only moves  Lefort II: maxilla & base of nose move:  Lefort III: whole face moves:

40.  Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor  Crepitus over maxilla  Ecchymosis in buccal vestibule  Epistaxis: can be bilateral  Malocclusion  Maxilla mobility

41.  Closed reduction  Intermaxillary fixation: secures maxilla to mandible  May need wiring or plating of maxillary wall and / or zygomatic arch  Antibiotics: anti-staphylococcal

42.  Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face

43. Signs & symptoms  Midface crepitus  Face lengthening  Malocclusion  Bilateral epistaxis  Infraorbital paresthesia  Ecchymoses: buccal vestibule, periorbital, subconjunctival

44.  Hemorrhage or airway obstruction may require emergent surgery  Treatment can often be delayed till edema decreased

45. Usually require  Intermaxillary fixation  Interosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary walls  May need additional suspension wires  Antibiotics

46.  Craniofacial dissociation  Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base

47. Signs and Symptoms  Face lengthening: “caved-in” or “donkey face”  Malocclusion: “open bite”  Lateral orbital rim defect  Ecchymoses: periorbital, subconjunctival

48. Signs and Symptoms  Bilateral epistaxis  Infraorbital paresthesia  Often medial canthal deformity  Often unequal pupil height

49.  Usually associated with major soft tissue injury requiring emergent surgery for bleeding control  Surgery can be delayed till edema resolves  Intermaxillary fixation

50.  Transosseous wiring or plating  Frontozygomatic suture  Nasofrontal suture  May need extracranial fixation if concurrent mandibular fracture  Antibiotics

51.  Nasal fracture  30 g  Zygoma fractures  50 g  Mandibular (angle) fractures  70 g  Frontal region fractures  80 g  Maxillary (midline) fractures  100 g  Mandibular (midline) fractures  100 g  Supraorbital rim fractures  200 g

52.  Airway obstruction from loss of attachment at base of tongue  >50 % are multiple  Condylar fractures associated with ear canal lacerations & high cervical fractures  High infection potential if any violation of oral mucosa

53. Signs and symptoms  Malocclusion  Decreased jaw range of motion  Trismus  Chin numbness  Ecchymosis in floor of mouth  Palpable step deformity

54.  Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.

55. Treatment  Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating

56.  Can occur from direct blow to mandible  Can occur “spontaneously” from yawning or laughing  Mandible dislocates forward & superiorly  Concurrent masseter & pterygoid spasm

57. Symptoms  Patient presents with mouth open, cannot close mouth or talk well  Can be misdiagnosed as psychiatric or dystonic reaction

58. Treatment  Manual reduction: place wrapped thumbs on molars & push downward, then backward  Be careful not to get bitten  Usually does not require procedural sedation or muscle relaxants

59.  Nasal fracture  30 g  Zygoma fractures  50 g  Mandibular (angle) fractures  70 g  Frontal region fractures  80 g  Maxillary (midline) fractures  100 g  Mandibular (midline) fractures  100 g  Supraorbital rim fractures  200 g

60.  Often diagnosed clinically: x-ray not needed  Emergent reduction not necessary except to control epistaxis  Usually do not need antibiotics  Early reduction under local anesthesia useful if nares obstructed

61.  Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours  Follow-up timing for recheck or reduction:  Children: 3 to 5 days  Adults: 7 days

62.  Nasal fracture  30 g  Zygoma fractures  50 g  Mandibular (angle) fractures  70 g  Frontal region fractures  80 g  Maxillary (midline) fractures  100 g  Mandibular (midline) fractures  100 g  Supraorbital rim fractures  200 g

63. Tripod (tri-malar) fracture  Depression of malar eminence  Fractures at temporal, frontal, and maxillary suture lines

64. Isolated arch fracture  Less common  Shows best on submental-vertex x-ray view  Painful mandible movement  Usually treat with fixation wire if arch depressed

65. Tripod S & S  Unilateral epistaxis  Depressed malar prominence  Subcutaneous emphysema  Orbital rim step- off  Altered relative pupil position  Periorbital ecchymosis  Subconjunctival hemorrhage  Infraorbital hypoesthesia

66.  Nasal fracture  30 g  Zygoma fractures  50 g  Mandibular (angle) fractures  70 g  Frontal region fractures  80 g  Maxillary (midline) fractures  100 g  Mandibular (midline) fractures  100 g  Supraorbital rim fractures  200 g

67. Frontal sinus fracture  Often associated with intracranial injury  Often show depressed glabellar area  If posterior wall fracture, then dura is torn

68. Ethmoid fracture  Blow to bridge of nose  Often associated with cribiform plate fracture, CSF leak  Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus

69.  “Blow out” fracture of floor  Rule out globe injury  Visual acuity  Visual fields  Extraocular movement  Anterior chamber  Fundus  Fluorescein & slit lamp

70. Symptoms and signs  Diplopia: double vision  Enophthalmos: sunken eyeball  Impaired EOM’s  Infraorbital hypesthesia  Maxillary sinus opacification  “Hanging drop” in maxillary sinus

71.  Diplopia with upward gaze: 90%  Suggests inferior blowout  Entrapment of inferior rectus & inferior oblique  Diplopia with lateral gaze: 10%  Suggests medial fracture  Restriction of medial rectus muscle

72.  Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery  Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

73.  Before repair, rule out injury to:  Facial nerve  Trigeminal nerve  Parotid duct  Lacrimal duct  Medial canthal ligament  Remove embedded foreign material to prevent tattooing

74.  For lip lacerations, place first suture at vermillion border  Never shave an eyebrow: may not grow back  If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically

75.  Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti- staphylococcal antibiotic) – no evidence  Remove sutures in 3 to 5 days to prevent cross- marks

76.  Most face bite wounds can be sutured primarily  Clean facial wounds can be repaired up to 24 hours after injury  Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)

77.  Assess ABC's first  Do complete exam as part of secondary survey  Obtain standard X-rays and / or CT scan as indicated  Decide if specialist referral and / or operative repair indicated

78.  Arrange followup after repair to assess for delayed complications or cosmetic problems