2. Introduction
The facial skeleton is divided into 3 parts
Upper 1/3-formed by frontal bone
Middle 1/3-from frontal bone to the level of upper
teeth
Lower 1/3-the mandible
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3. The causes of maxillofacial injuries
Fights
Falls
Road traffic accidents
Occupational hazards-athletic injury, industrial
mishaps
Iatrogenic causes-# of tooth, alveolus,maxillary
tuberosity,# of mandible during dental treatment.
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4. Examination of patient with maxillofacial trauma
History of injury
Obtained from the patient or relatives or the witness
of injury.
Who-name,age,sex,address,phone number
When-date & time of injury.
Where-the surroundings of injury.
How-type of violence & direction of force.
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5. Cont.
What-type of treatment given before the patient
comes here.
What- is the general health of the patient.h/o
allergy,bleeding disorders,any systemic bone
disease,neoplasm,arthritis
Previous h/o trauma
Length of unconciousness
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10. Clinical examination of maxillofacial injuries
Extraoral examination
Patient`s face is gently washed with warm saline or
water prior to examination.
Inspection
Length, breadth & depth of soft tissue wound is
measured.
Nose & ear are inspected for bleeding or csf leak.
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12. Cont.
Motor function of facial &masticatory muscles are
noted.
Intranasal laceration, septum deviation are noted.
Palpation
Palpation is started at the back of the head for
wounds & bony injuries.
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13. Cont.
Then the palpation is done in the forehead, the
fingers are kept in the midline & go sideways over
supraorbital rims,infraorbital rims,zygomatic bones
& arch.
Areas of tenderness,step deformities or abnormal
mobility are noted.
Nasal bridge palpation is started from the top till the
nasal tip.
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15. Cont.
CSF leak may form a` halo ` effect on pillow or bed
sheets-ring test.since CSF is more viscous it forms
the central circle encircled by blood.CSF will not
stiffen the cloth whereas other secretions do so.
TMJ evaluation is done by placing the index fingers
on preauricular area or on the external auditary
meatus.all movements are checked.
Palpate the inferior border,posterior border for
tenderness & deformity
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16. Intraoral examination
Inspection
Oral cavity is thoroughly irrigated prior to
inspectionmouth wash can be used.
Restriction of oral opening, gagging of
occlusion,lacerations,ecchymosis,damage to teeth &
alveolus are noted.
Buccal & lingual sulci are inspected for
wound,ecchymosis,sublingual hematoma
Loose teeth, occlusion are noted.
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17. Cont.
Step deformity in dental arch is noted.
Palatal mucosa is inspected for tear & bleeding.
Palpation
Buccal & lingual sulci are palpated for tenderness,
crepitus & mobility of teeth.
Mandible is palpated bimanually & unnatural
mobility is noted.
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18. Cont.
For assessing maxillary mobility,patient`s head is
stabilized using one hand over the forehead & with
thumb & fore finger of other hand maxilla is grasped
with firm pressure to elicit maxillary mobility.
Rock the maxillary alveolar segments to detect
fractures of alveolus or split in palate.
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19. Radiologic examination
For # of middle 1/3 of face
PA view skull
Water`s view
Lateral view skull
Submentovertex view
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21. Cont.
For # of mandible
OPG
Right & left lateral oblique view of mandible
PA view mandible
Occlusal view
IOPA
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22. Basic principles to be followed for preservation of
life in a trauma patient
Maintenance of patency of airway
Bleeding control
Maintenance of circulation
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23. Maintenance of airway
Position of the patient:-supine with neck
extended or head turned sideways.
Oropharyngeal toilet:-all blood clot,sliva thick
mucous, friegn bodies should be cleared by digital
exploration or by using cotton swabs.
Suction:-to clear nose,oral cavity &throat.
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24. Cont.
Anterior traction of tongue:-tongue is pulled
out & is held in position by tongue suture or towel
clip.
Restoration of position of soft palate:-by
disimpaction of maxilla.it is done by placing
index & middle finger hooking behind the soft
palate & thumb on the alveolus in the incisor
region.head is stabilized with the other hand over
the forehead.anterior & downward traction will
bring maxilla to normal position.
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26. Bleeding control
Compression dressing
Major vessels are clamped or ligated.
Soft tissue wounds are sutured.
Deep wounds are packed with guaze.
Nasal bleeding is stopped by using ribbon guaze
soaked in 1:1000 adrenaline.
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27. Maintenance of circulation:-
If the patient is in shock,iv fluids are started to
restore the blood volume.
After crossmatching blood transfusion is started.
Pulse,resp.rate,bp should be monitored.
Control infection by antibiotics & anti-inflammatory
analgesics through iv route.
Tt is given.
Adequate nutrition is given.
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28. Management of soft tissue injuries
Abrasions
Caused by frictional violence.
It is presented as raw bleeding areas.
Through cleaning is done with profuse saline
irrigation.
Remove the foreign materials.
Gentle scrubbing is done with soft brush to remove
sticky material.
Topical application of antibiotic ointment with
compression dressing is given
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29. Cont.
Superficial abrasions are covered with topical
antibiotic & is left open
Contusion
Caused by a blow or fall against a hard or blunt
object.
Blood extravasates in subcutaneous tissue leading to
bluish area or bruise.
Application of ice pack will help to stop further
extravasation .
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30. Cont.
Hematoma
It is the localized collection of blood in subcutaneous
or intramuscular or submucosal space.
It may be associated with fracture or rupture of
vessels.
Most of them are reabsorbed.
Persistant hematomas may require incision &
drainage.
Antibiotic coverage is given to prevent infection of
hematoma.
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31. Cont.
Lacerations
Here tearing of mucosa or skin is seen.
There may be associated injury to
vessels,nerves,muscles & bone.
Thorough cleaning,minimum debridement,removal
of foreign bodies & proper suturing is done.
Suturing is done in multiple layers
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32. Cont.
Incised wounds
Caused by sharp objects.
They are clearcut, gaping,bleeding wounds with
minimum contamination.
The wound is cleaned,bleeding is arrested.
Wound is closed by primary intension
Penetrating & punctured wounds
Caused by pointed objects.
Externally they appear small, but they may be deep
penetrating endangering vital organs.
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33. Cont.
Crushed wounds:-
Crushing of the parts with laceration is seen.
Crushing of musculature is seen.
Damage to blood vessels & nerves may be seen.
Bone may be shattered.
There may be loss of soft or hard tissues.
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34. Cont.
Gunshot injuries:-
They can be
Penetrating wound-missile is retained in the wound
Perforating wound-missile produces another wound of
exit.
Avulsive wounds-large portion of soft tissue or bone is
desroyed.
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35. Supportive therapy of soft tissue wounds
Drains:-for deeper wounds in oral cavity drains
may be placed b/w sutures .it is removed after 2 to 4
days.
Dressings:-antibiotic ointment with dry guaze
dressing is changed in every 48hrs.sutuires are
removed on 5th
or 7th
day.
Prevention of infection:-sterile technique &
supportive antibiotic therapy.
Prophylaxis against tetanus
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36. Factors causing failure of wound healing
Too tight suturing.
Inadequqte pressure dressing.
Oral contamination of wound.
Secondary haemorrhage.
Inadequate antibiotic therapy.
Rough handling of wounds.
Foreign body inclusion.
Compromised vascularity.
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38. Basic principles of management of
fracture
Reduction
Fixation
Immobilization
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39. Reduction
It is the restoration of fractured fragments to their
original position.
Reduction is brought about by closed reduction or
open reduction.
Closed reduction
It can be carried out by manipulation or by traction.
No surgical intervention is needed for closed
reduction.
Occlusion of teeth is used as the guiding factor.
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40. Cont.
Reduction by manipulation
Done when the fragments are adequately mobile
witout much overriding or impaction & patient
comes immediately comes after trauma.
Digital or hand manipulation is used for reduction.
Disimpaction forceps or bone holding forceps can be
used.
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41. Cont.
Reduction by traction
Prefabricated arch bars are attached to maxillary &
mandibular arches by interdental wiring.
The fractured fragments are subjected to gradual
elastic traction by placing elastics from upper to
lower arch.
Open reduction
Surgical reduction that allows visual identification of
fractured fragments.
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42. Fixation
Fractured fragments are fixed to prevent
displacement & for achieving proper approximation.
Direct skeletal fixation :-by plates or intraosseous
wiring.
Indirect skeletal fixation:-by arch bar or
intermaxillary fixation.
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43. Immobilization
The fixation device is retained to stabilize the
reduced fragments until a bony union takes place.
For maxillary # 3 to 4 weeks immobilization is
enough.
For mandible # 4 to 6 weeks immobilization.
In condylar # 2 to 3 weeks immobilization to prevent
ankylosis.
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44. Arch bars
It has hooks incorported on the outer surface with
malleable stainless steel metal strip
The bar is cut to the length of dental arch.
Arch bar is fixed to both the arches.
On the upper jaw the hooks are arranged in upward
direction.
Archbar is adapted by bending the archbar starting
from the buccal side of last tooth.
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45. Cont.
The arch bar is fixed to the tooth with 26 guage
wire,one end of wire is above & the other below the
arch bar.
The twisting of the wire is done in clockwise manner.
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47. Bone plate osteosynthesis
Indications
If imf is contraindicated
Edentulous patients with loss of bone segments.
If early mobilization of joint is required as in condylar #
Contraindications
Heavily contaminated # with active infection &
discharge.
Badily comminuted #.
In mixed dentition period.
Presence of gross pathologies in bone.
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48. Cont.
Precautions
Strict aseptic procedure is required.
Patient should be kept on preoperative antibiotics.
Plates and screws should be of same metal.
Minimum 2 screws should be used on each side.
The drill bit should be perpendicular to the cortex.
Patient should maintain good oral hygiene.
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50. Cont.
Procedure
The intrafragmentary gap is less than 0.8mm .
Occlusal relationship is checked prior to screw
fixation.
Plates & screws are made up of stainless steel or
titanium & is removed later.
In compression bicortical screw system:-the outer
oblique holes produce additional compression.
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51. Cont.
In monocortical noncompression screw system
(miniplte osteosynthesis):-stability is achieved by
perfect anatomic reduction & intrafragmentary
approximation without compression.
Miniplates are 2cm long.0.9 mm thick &6mm wide.
Screws have a thickness of 3.3mm.
The screws should be self tapping.
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