Maxillofacial Trauma

Maxillofacial Trauma El-Hawary

DEFINITION

Trauma
Serious injury or shock to the body as form of
violence or accident
Bone fracture
A medical condition in which there is a break in
the continuty of bone

CLASSIFICATIONS

• Soft tissue wounds
• Soft tissue wounds and fracture bones
• Bone fractures only

WOUNDS
• Type of injury in which skin is torn, cut or
punctured (an open wound), or where blunt
force trauma causes a contusion (a closed
wound)
• In pathology: it specifically refers to a sharp
injury which damages the dermis of the skin

Classifications of wounds
wound
According to the
exposure to the
outer
environement
According to
level of risk of
sepsis

Classification according to the exposure to the outer
environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury

Classification according to object causing wound
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury

wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury

environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury
http://woundbegone.blogdrive.com/

environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury http://en.wikipedia.org/wiki/File:Knee_puncture.JPG

wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury
http://journal.nzma.org.nz/journal/120-1267/2867/

environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush injury http://www.podiatrytoday.com/article/6303

environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury
http://en.wikipedia.org/wiki/File:Bruises.jpg

environment
wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury
http://www.buzzle.com/articles/hematoma-treatment.html

wound
Open
Incision
Laceration
Abrasion
Puncture
Penetration
Gunshot
Closed
Contusion
Hematoma
Crush
injury http://www.smrteam.com/na1_crushinjury.htm

Classification According to level of risk of sepsis

wound
Clean wound
Clean
contaminated
wounds
Contaminated
wounds
Dirty wounds

wound
Clean wound
Clean
contaminated
wounds
Contaminated
wounds
Dirty wounds
• No viscus entered
• No septic area
• No break in aseptic technique
• Such wounds should never become
infected; infection rates less than 3%

wound
Clean wound
Clean
contaminated
wounds
Contaminated
wounds
Dirty wounds
• Operation enters a non-infected area but
may encounter bacteria
• Careful control of the area should result in
minimal spillage of organisms
• Examples of this include surgery on the
upper gastrointestinal tract, biliary tree or
respiratory tract
• Infection rates for this type of surgery should
be less than 10%

wound
Clean wound
Clean
contaminated
wounds
Contaminated
wounds
Dirty wounds
• Gross spillage of organisms, where there is
infection already present but without pus
formation
• There is a major break in aseptic technique
• There is an open wound that has been
exposed for less than 4 h (e.g. following
major trauma)
• In this type of wound, sepsis frequently
exceeds 30%

wound
Clean wound
Clean
contaminated
wounds
Contaminated
wounds
Dirty wounds
• This is an operation through an infected area
(e.g. perforated viscus, abscess or traumatic
wound) that has been exposed for over 4 h

Classification of wound healing
• Primary Intention
• Occurs when:
– The edges are clean and held
together with ligatures
– There is little gap to bridge Healing
• Healing properties (When
uncomplicated)
– Occurs quickly
– Rapid ingrowth of wound healing
cells (macrophages, fibroblasts, etc.)
– Restoration of the gap by a small
amount of scar tissue.
• soundly united within 2 weeks
• Dense scar tissue is laid down
within 1 month

Classification of wound healing
• Secondary Intention
• Occurs when:
– The edges are separated
– The gap can not be directly bridged
– Extensive epithelial loss
– Severe contamination
– Significant subepithelial tissue damage
• Healing properties
– Occurs slowly
– Granulation; healing from the bottom
towards the surface
– Restoration of the gap by a small
amount of scar tissue.
• Scaring
• Wound contracture

Differences between primary and secondary
healing
Feature Primary healing Secondary healing
Cleanness Clean Unclean
Infection Generally uninfected May be infected
Margins Surgically clean Irregular
Healing Scanty granulation tissue Granulation tissue fill the gap
Healing period Short long
Healing direction Direct healing From the bottom to the edge
Outcome Neat linear scar Contracted irregular wound

Normal sequence of wound healing

Phases of wound healing
Days Weeks Months
Hemostasis

Days Weeks Months
Hemostasis
Inflammation

Days Weeks Months
Hemostasis
Inflammation
Proliferation

Days Weeks Months
Hemostasis
Inflammation
Proliferation
Maturation & Remodeling

http://en.wikipedia.org/wiki/File:Wound_healing_phases.png

Factors affecting healing
Factors
Local
factors
Wound
sepsis
Blood
supply
Wound
tension
Foreign
bodies
Previous
irradiation
Poor
technique
Systemic
factors
Nutritional
deficiencies
Systemic
diseases
Therapeutic
agents
Age

Complications of wound healing

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Treatment
• Prophylactic antibiotics
• Empirical antibiotic
• Therapeutic /specific antibiotics
• I&D
• Antiseptic packs

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Definition: Total breakdown of all the layers of the
surgical repair of a wound
• Etiology / causes:
• Suture breakage
• Knot slippage
• Cutting out of sutures
• Excess tension on the suture line
© 2009 Nucleus Medical Art, Inc.
http://www.empowher.com/media/reference/wound-dehiscence

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Definition: Breakdown of the deeper layers of a wound in
which the skin layer remains intact with protrusion of
underlying structures through the deeper defect
http://www.melbournegallbladder.com.au/patientinfosheets/info_incisional_her
nia/info-incisional-hernia-gen-1.htm

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Treatment:
• Difficult
• Further surgery should not be attempted for at least
6 months
• Excision of the scar and re-suturing often has
disappointing results, resulting in the same over
healing
• Radiotherapy used to be used but has now been
abandoned
• Some improvement can be achieved with local
injection of corticosteroids directly into the scar, a
process that might need repeating several times
http://www.ehow.com/about_5422431
_natural-herbs-hypertrophic-scars.html

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Treatment:
• Excision generally results in a larger recurrence
• Although excision followed by compression
bandaging can have slightly better results
• Corticosteroid injections give some improvement

complications
Infection
Dehiscence
Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
• Wound Contractures can occur with any wounds
• More commonly with delayed healing wounds
• Contracture of a scar across a joint can result in marked
limitation of movement
• Surgical treatment include
• Skin grafting
• local flaps
• wound Z-plasty
http://www.patient.co.uk/health/D
upuytren%27s-Contracture.htm

SKELETAL TRAUMA

ETIOLOGY

• Motor vehicle accidents (MVA)
• War injuries
• Civilian accidents
• Falls, altercations
• Animal bites or kicks (dogs, horses, camels)
• Pathological
• Iatrogenic

EMERGENCY

First Aid Treatment
• Airway
• Breathing
• Circulation
• Drugs

First Aid Treatment
Airway management

DIAGNOSIS

Clinical
Examination
Radiographic
Evaluation
Advanced
diagnostic
History
Diagnosis

Clinical
Examination
Inspection Palpation Auscultation

Clinical
Examination
Inspection Palpation
Bimanual Bidigital
Auscultation

Clinical Examination
• Systemic examination:
- Vital signs
- Level of consciousness
- CNS
- CSF leakage

Clinical Examination
• Signs & Symptoms:
- Ecchymosis
- Edema
- Soft tissue wounds
- Malocclusion
- Trismus
- Segment mobility
- Steps or deformities

Radiographic
evaluation
Plain Radiography
IntraOral
Techniques
ExtraOral
Techniques
Advanced
Radiographic
Techniques

Techniques
Plain Radiography
IntraOral
Techniques
ExtraOral
Techniques
Advanced
Radiographic
Techniques
1. Periapical
Radiograph
2. Occlusal
Radiograph

Techniques
Plain Radiography
IntraOral
Techniques
ExtraOral
Techniques
Advanced
Radiographic
Techniques
1. Panoramic Radiograph
2. PA Radiograph
3. Occlusal Radiograph
4. Lateral Radiograph
5. Lateral Oblique

Techniques
Plain Radiography
Advanced
Radiographic
Techniques
1. CT Scanning
2. Dental CT scaning
3. Cone Beam CT Scanning

Advanced Diagnostic Modalities
1. MRI
2. Ultrasonography
3. SPECT

II. Radiographic Examination

TYPES

Dentoalveolar Fractures

• Ellis Classification:
I. Fx within enamel
II. Fx of enamel & dentin
III. Fx involving pulp
IV. Root fx

1. Periodontal Injuries:
i. Concussion
ii. Displacement (Luxation)
a. Subluxation
b. Intrusive luxation
c. Extrusive luxation
d. Lateral luxation
e. Avulsion
2. Fx of the Alveolar Process

Mandibular Fractures

• Classification:
I. According to Site:
a. Symphyseal
b. Parasymphyseal
c. Body
d. Angle
e. Ramus
f. Condyle
g. Coronoid

Anatomical distribution and frequency of mandible
fractures
(Haug, Parather, Indresano, 1990)

• Classification:
II. According to Side:
a. Unilateral
b. Bilateral
III. According to number of lines:
a. Single
b. Multiple

• Classification:
IV. According to nature of fracture:
a. Green stick
b. Simple
c. Compound
d. Comminuted

• Classification:
V. According to degree of displacement:
a. Favorable fractures
b. Unfavorable fractures

Factors affecting the displacement of
fracture
• Direction of the fracture line (favorable/unfavorable)
• Direction of muscle pull (elevators/depressors)
• Presence/absence of teeth
• Direction and magnitude of the traumatizing force

Champy’s principles

Condylar Fractures

Classification of the TMJ region injury
1. Contusion :
- Damage to the capsular ligaments
- May be accompanied by :
Synovial effusion. (Rowe & Kelly,2nd ed,1970)
Haemarthrosis. (Bosanquet et al., 1990, Jones et al., 1991)
Tearing of the meniscus &/or displacement of the articular
disk. (Faustia et al., 1990)
2. Dislocation : (Sullivan et al., 1995)
- Irreducible displacement of the condoyle from the glenoid fossa.
- Direction of displacement:
Anterior, medial (usually).
Lateral, posterior or central (rare).
3. Fracture:
- Any fracture above the level of the segmoid notch.
- It may be:
intracapsular i.e. within the capsule involving the condylar head or
neck.
extracapsular i.e. outside the capsule in the subcondylar region.

Classification of Condylar fracture
(Lindahl, 1977)
A. Classification according to the fracture
level:
1. Condylar head (Intracapsular).
2. Condylar Neck.
3. Subcondylar (high or low).
B. Classification according to the relation of
condyle to Mandible:
1. Non displaced.
2. Deviated or angulated.
3. Displaced ( M or L/A or P overlap).
4. No bony contact.
C. Classification according to the relation of
condyle to the Glenoid Fossa:
1. Non Displaced.
2. Displaced-still related to fossa.
3. Dislocation-completely out of fossa.

Mechanism of injury
 Provide clues about the
magnitude and direction of
force delivered to the patient.
 The more force delivered, the
more severe the fracture.
 The direction of force
influence the fracture
pattern. (Spina
& Marciani, 2000)
Forces resulting in Trauma to the
TMJ:
1. Moving object striking a static
individual.
2. Moving individual striking a
static object.
3. Combination of forces.

Maxillary Fractures

Maxillary Fractures
• Classification:
– LeForte I (Transverse fracture):
Transversely through maxilla above teeth
level, lateral antral wall, lower
pterygoid plates.

Maxillary Fractures
• Classification:
– LeForte II (pyramidal fracture):
Nasal bone, maxillary frontal process, lacrimal bone, inf. orbital rim,
Zygomaticomaxillary suture, lat. maxillary wall, pterygoid plates,
pterygomaxillary fossa.

Maxillary Fractures
• Classification:
– LeForte III (craniofacial dysjunction):
Zygomaticofrontal, maxillofrontal and nasofrontal sutures

Zygomatic fractures

TREATMENT

• The aim of mandibular fracture treatment is
– Reduction
• Restoration of anatomical form
• Restoration of function
• Establish proper occlusion
– Fixation Immobilization
– Stabilization
– Prevention of infection

Treatment
Reduction Fixation

Treatment
Reduction Fixation
Open Closed

Treatment
Reduction Fixation
Open Closed Rigid Non-rigidSemi-rigid

Treatment
Reduction Fixation
Open Closed Rigid Non-rigid
Open
reduction
Rigid fixation
Semi-rigid

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Semi-rigid
Plates and osteosynthesis
Screws osteosynthesis
K-wires

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Semi-rigid

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Semi-rigid
Mini-plates osteosynthesis

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Semi-rigid
Wire osteosynthesis

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation
External pin fixation

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Closed
reduction
Semi-rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Closed
reduction
Semi-rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation
Lingual splint

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Closed
reduction
Semi-rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation
Closed
reduction
Non-rigid
fixation

Treatment
Reduction Fixation
Open
reduction
Rigid fixation
Open
reduction
Semi-Rigid
fixation
Open
reduction
Non-Rigid
fixation
Closed
reduction
Semi-rigid
fixation
Semi-rigid
Closed
reduction
Rigid fixation
Closed
reduction
Non-rigid
fixation
Wiring techniques
MMF

Rigid versus Non-rigid Fixation

Advantages of Rigid Fixation
1. Pts with poor or inadequate dentition
2. Avoidance of debilitating weight loss
3. No interference with speech
4. Suitable for pts with seizures or alcoholism
5. Immediate return to work and normal life
style
6. Risk of infection reduced

Advantages of Rigid Fixation
7. Avoidance of TMJ disturbance especially in cases
with condylar fracture
8. Fewer complications as non- or malunion (1ry
rather than 2ry bone healing)
9. Safer airway and decreased risk of aspiration
10. Allows for proper oral hygiene
11. Ability to obtain and maintain precise anatomic
reduction of fractured segments

Effects of Intermaxillary Fixation
• On the following tissues
– Muscles
– TMJ
– Bone
– Periarticular C.T.

Factors affecting the selection of the Surgical
approaches for open reduction
1. The level of the fracture.
2. The degree of displacement or dislocation.
3. The planned method of the fixation.
4. Langer’s lines

http://www.beltina.org/health-dictionary/langers-lines-skin.html

http://hi.baidu.com/hilygogo/blog/item/35cbe8f0db3a7baba50f5271.html

Factors affecting the selection of the line of
treatment
1. Factors related to the patient
– Age of the patient.
– Well
– Systemic condition
2. Factors related to the fracture
– Site, type and level of fracture.
– Degree of displacement.
– Condition of the post injury occlusion.
3. Factors related to the operator
1. Conditions
2. Skill
3. Armamentarium

TREATMENT MODALITIES

Fixation of Mandibular Fractures
II. Open Reduction Techniques (direct fixation
techniques) ORIF:
1. Non-rigid: (needs supplementary fixation, IMF)
a. Transosseous (intraosseous) wiring

Fixation of Mandibular Fractures
II. Open Reduction Techniques (direct fixation
techniques) ORIF:
2. Rigid: (sole fixation methods)
a. Intramedullary Pinning: Kirchner wires, Steinmann
pins.
b. Metal Mesh plates: Titanium mesh
c. Bone plates and screws: mono- or bicortical
d. Lag Screws
e. Biodegradable (resorbable) bone screws
f. Bone Clamps

Open Reduction Techniques (direct
fixation techniques) ORIF:

• Bone plates:

• Lag screws:

• Biodegradable plates:

• Bone clamps:

Treatment of Maxillary Fractures

Condylar Fx Treatment modalities
Treatment modalities
Conservative treatment Open reduction
Close Observation Closed reduction

Observation
Indications:
- Well aligned segments (no displacement).
- Repeatable occlusion without pain.
- Children under 12 years of age, with minimal
fracture displacement and normal occlusion.
Technique:
- Clinical observation.
- Soft diet.
- Active function.
- Physiotherapy.

Closed reduction
Indications:
- Correctable Malocclusion.
- Deviation of the mandible with function.
- Pain.
Technique:
- Immobilization (7-21 days) in the form of arch bars, Ivy
loops or individual wiring followed by active
mobilization and physiotherapy.
- Period of immobilization depend on:
Age of the patient.
Level of fracture.
Degree of displacement.

Indications for open reduction
(Zide & Kent, 1983)
Absolute indications Relative indications
1. Bilateral condylar fracture with
concomitant comminuted
midfacial fracture.
2. Bilateral condylar fracture in an
edentulous patient when splints
are unavilable or imposible
because of sever ridge atrophy.
3. Displaced condyle in an
medically compromised patient
where MMF is contraindicated.
1. Inability to obtain adequate
occlusion with closed reduction.
2. Displacement of the condyle
into the middle cranial fossa.
3. Lateral extracapsular
displacement.
4. Foreign body in the joint
capsule.

Summary of treatment

Management of condylar fractures in children
According to the degree of displacement:
 Undisplaced / minimally displaced
condylar fractures:
Conservative non immobilization with
active function.
 Severly displaced with malocclusion:
7:10 days immobilization followed up by
acyive function and physiotherapy.

Postoperative instructions /medications
• Good oral hygiene
– Teeth brushing
– Rinse utilizing warm saline and mouth wash
• Semi-solid feeding was ordered for the patients on
the second postoperative day and until the end of
MMF period.
• Prophylactic Antibiotics-one week postoperatively
• Anti-edemic
• Analgesics

THANK YOUTHANK YOU

Maxillofacial Trauma

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