Category Archives: Soft Tissue and Dentoalveolar Injuries

lacerations

lacerations
The general guidelines for management of facial lacerations are outlined in Chapter 23 ..Frequently, fractures of the facial bones are associated with severe facial lacerations. The principles of laceration repair remain’ the same
regardless of how small or large the injury.

ftG. 24-31 A, Patient (who 'sustalned severe pantacial trauma from an industrial accident) in the operating department is shown in a C-spine collar. 5, Axial computerized tomography (CT) scan reveals anterior skull fractures with intracranial air. C. Axial CT scan with bilateral displaced mandible fractures. D, Operative view of skull vault plated while the neurosurgeon was repairing the duraltear.

ftG. 24-31 A, Patient (who ‘sustalned severe pantacial trauma from an industrial accident) in the
operating department is shown in a C-spine collar. 5, Axial computerized tomography (CT) scan
reveals anterior skull fractures with intracranial air. C. Axial CT scan with bilateral displaced mandible
fractures. D, Operative view of skull vault plated while the neurosurgeon was repairing the duraltear.

 

FIG 24-31

FIG 24-31

FIG 24-31

FIG 24-31

FIG 24-32 AND FIG 24-33

FIG 24-32 AND FIG 24-33

FIG. 2-+·:>~ A., Chainsaw injury to the lips, jaws, and chin, resulting in loss of teeth and bone. B, View from above after hemostasis has been achieved and the wound has been debrided and trimmed. Note the nearly avulsed upper lip pedicled on the left side. C, View of repaired lacerations with patient nasally intubated and an oral airway in place. D, Three-month postoperative facial appearance.

FIG. 2-+·:>~ A., Chainsaw injury to the lips, jaws, and chin, resulting in loss of teeth and bone. B, View
from above after hemostasis has been achieved and the wound has been debrided and trimmed. Note
the nearly avulsed upper lip pedicled on the left side. C, View of repaired lacerations with patient nasally
intubated and an oral airway in place. D, Three-month postoperative facial appearance.

 

 

 

 

 

 

 

 

 

 

 

 

 

Midface Fractures

Midface Fractures
Treatment of fractures of the midface can be divided into those fractures that affeci, the occlusal relationship, such as Le Fort I, IC or III fractures, and those fractures that do not necessarily affect the occlusion, such as fractures
of an isolated zygoma, zygomatic arch, or NO[‘ complex.

Suspension ·wiring is sometimes used in addition to direct wiring or bone plating. The purpose of suspension. , wiring is to provide stabilization of fractured bones by suspending them to a more stable bone superiorly. B Suspension wiring techniques include those with wires attached to’ the piriform rim area, infraorbital rims, zygomatte arch, or frontal bone (Fig. 24-29). The suspension wires can be connected directly to the maxillary arch wire, or-they can be connected withan intermediate wire to an interocclusal splint or to the mandible. These.suspension wires prevent movement of the maxilla caused by the inferior pull of the mandible during attempted opening, The use of direct and. suspension wire fixation
docs have significant limitations in many cases, The lirn

FIG 24-28

FIG 24-28

FIG 24-29

FIG 24-29

FIG 24-30

FIG 24-30

ited rigidity of wires may make it difficult fa’ reconstruct and maintain the appropriate anatomic contours, partie- • ularly in concave and convex areas, such as orbital rims and the prominence of the zygoma. Wires may not provide adequate resistance to muscular forces during the entire healing period, eventually resulting in some fracture displacement.

 

 

 

 

Mandibular Fractures

Mandibular Fractures
The first and most important aspect of surgical correction is to reduce the fracture properly or place the individua  segments of the fracture into the proper relationship with

FIG 24-17

FIG 24-17

each other. In the proper reduction of fractures of toothbearing bones, it is most important to place the teeth into the preinjury occlusal relationship. Merely aligning’ and interdigitattng-rhc bony fragments at the fracture sitewithout first establishing ‘a proper occlusal relatioriship rar ely results ill satisfactory. postoperative functional occlusion.

FIG 24-18

FIG 24-18

FIG 24-20

FIG 24-20

In the case of a fracture of an edentulqus patient, the mandibular dentures can be wired to the mandible with circum mandibular wiring, and the maxillary denture can

FIG 24-20

FIG 24-20

whom placement of arch bars and hone plates is difficult because of the configuration of ‘the deciduous teeth. because of developing permanent teeth, and because patient understanding and cooperation is difficult to
obtain. After a complete clinical and radiographic examination, all fractures and soft tissue injuries should Iw identified and categorized. Then, with input from the patient and the patient’s family, a treatment plan should
be. developed as to method and sequencin-g of surgl·ry. Discussion regardi ng closed ,:ersus open reduction. allY ·’period of 1\11\11a’,nd anticipated morbidity should lead to a decision, and surgical consent should be obtained.

FIG 24-20

FIG 24-20

weeks. Indications for open reduction include continued displacement of the bony segments or an unfavorable fracture, such as in an angle fracture (see Fig. 24-13), in which the pull of the masseter and medial pterygoid muscles can cause distraction of the proximal segment ;.’1 tho.’ mandible. With rigid fixation techniques, patients “.an ‘of

FIG 24-21

FIG 24-21

FIG 24-22

FIG 24-22

When open reduction is performed, direct surgical access-to the area of the fracture must be obtained. This access’ can be accomplished through several surgical – approaches, depending on the area of the mandible fractured. Both intraoral and extraoral approaches are possible.
Generally the symphysis and anterior mandible areas can be easily approached through an intraoral incision (Fig. 24-22), whereas posterior angle or ramus and condition

FIG 24-23 AND FIG 24-34

FIG 24-23 AND FIG 24-34

Currently techniques for rigid internal fixation ‘arc widely used for treatment of fractures. 7,11  use bone plates, bone screws, or both to fix t~1’:’~’f;l(‘t.r.c more rigidly and stabilizethe bony segments during hl·al-
·ing. (Fig. 24-26). Even with rigid fixation, a proper

FIG 24-25 AND FIG 24-26

FIG 24-25 AND FIG 24-26

FIG 24-26

FIG 24-26

FIG 24-26

FIG 24-26

FIG 24-27

FIG 24-27

occlusal relationship must ‘be established before reduction stabilization and flxatien of the bony segments. Advantages of rigid fixation techniques for treatment of mandibular fractures include decreased discomfort and
inconvenience to the patient because MMF is eliminated or reduced, improved postoperative nutrition, improved postoperative hygiene, greater safety for seizure patients, and, frequently, better postoperative management of patients with multiple injuries.

 

 

 

 

 

 

 

 

 

TREATMENT Of FACIAL FRACTURES

TREATMENT Of  FACIAL FRACTURES
Whenever facial structures are injured, treatment must be directed toward maximal rehabilitation of the. patient . For facial fractures, treatment goals include rapid bone, healing; a return of normal ocular. masticatory; and nasal
function; restoration of speech; and an acceptable facial . and dental esthetic result. During the treatment and healing phases, it is also importantto Illinimize the adverse effect on’ the patient’s nutritional status and achieve
treatrrient goals with the least amount of discomfort and inconvenience possible.

The timing of treatment of facial fractures depends on many factors. In general, it is always better to treat an injury as soon as possible. Evidence shows that the longer open or compound wounds are left untreated, the greater is the incidence of Infection. In additjon, a delay of several
davs or weeks makes an ideal anatomic reduction of the – fracture difficult if not impossible. Additionally, edema progressively worsens over 2 to 3 days after an injury and frequently makes treatment of a fracture’ marl’ difficult.

r.: Ca , 2·"· 1~, Le Fort midfacial fractures. A, Le Fort I fracture separating 'inferior portion of maxilla in horizontal fashion, extending from piriform aperture of nose to pterygoid maxillary suture area. 8, Le Fort II fracture involving separation of maxttla and nasal complex from cranial base, zygomatic orbital rim area, and pterygoid maxillary suture area. C, Le Fort III fracture (i.e., craniofacial separation) is complete separation of midface at level of nasoorbital-Ethmoid complex and zygomaticofrontal suture area. Fracture also extends through orbits bilaterally .:

r.: Ca , 2·”· 1~, Le Fort midfacial fractures. A, Le Fort I fracture separating ‘inferior portion of maxilla in
horizontal fashion, extending from piriform aperture of nose to pterygoid maxillary suture area. 8, Le
Fort II fracture involving separation of maxttla and nasal complex from cranial base, zygomatic orbital
rim area, and pterygoid maxillary suture area. C, Le Fort III fracture (i.e., craniofacial separation) is
complete separation of midface at level of nasoorbital-Ethmoid complex and zygomaticofrontal suture
area. Fracture also extends through orbits bilaterally .:

Although treatments of maxillary and mandibular’ fractures frequently have many aspects in common, these types of fractures arc addressed separately in this chapter: Traditionally the plan for treatment of most facial fractures was to begin with reduction of mandibular fractures
and worksuperiorly through the midface. The rationale was that the mandible could be most easily stabilized, and the occlusion and remainder of the facial skeleton could be set to the reduced mandible. However, with the advent of and improvement in rigid fixation techniques: faci~l fracture treatment -may begin rn the area where fractures can be most easily stabilized anti progrevse- to the most’ unstable fracture areas .

FIG. 24-15 A, Zygomatic complex fracture. B, Lateral view. Isolated zygomatic arch fracture. C, Submental vertex view. (A and C modified from Kruger E, Schilli W: orar and maxillofacial traumatology, vol 1, Chicago, 1982, Quintessence.)

FIG. 24-15 A, Zygomatic complex fracture. B, Lateral view. Isolated zygomatic arch fracture. C, Submental
vertex view. (A and C modified from Kruger E, Schilli W: orar and maxillofacial traumatology, vol
1, Chicago, 1982, Quintessence.)

In approaching facial fractures, the surgeon attempts to rebuild the face based on the concept that certain bony structures within the face provide the primary support in the vertical and anteroposterior directions. Three buttresses exist bilaterally that form the primary vertical sup- .ports of the face: (1) the nasomaxillary, (2) the zygornatlc, ana (3) the pterygornaxillary buttresses (Fig. 24-17).6 The structures that support the facial projection in an anterior-posterior direction include the frontal bar, zygomatic arch and zygoma complex, maxillary alveolus and palate, and the basal segment of the mandible’? Regardj less of the type of facial fracture or the surgical approach used, the initial procedure should be to place the teeth in the proper occlusion and then appropriately reduce the bony fractures. Bony repair should also precede soft tissue repair.

 

Midface Fractures

Midface Fractures
Midfacial fractures inciude fractures affecting the maxilla, the zygoma, and the NOE complex. Midfacial fractures can be classified as Le Fort I, II, or III fractures, zygomaticomaxillary complex (ZMC) fractures, zygomatic arch fractures, or NOE fractures. These injuries may be isolated or occur
in combination.

The most common type of midfacial fracture is the zygomatic complex fracture (Fig. 24-15, A). This type of fracture results when an object, such as a fist or a baseball, . impacts over the lateral aspect of the cheek. Similar trauma
can also result in isolated fractures of the nasal bones, the orbital rim, or the orbital floor areas (Fig. 24-16). The zygomatic arch may also be affected, either alone or in combination with other jnjuries (see Fig. 24-15, Band C).

Mandibular Fractures

Mandibular Fractures
Depending on thetype of injury and the direction and force of the trauma, fractures of the mandible commonly occur in several locations. One classification of fractures

FIG. 24-11 Anatomic distribution of mandibular fractures. (From Olson RA et 0/: Fractures of the mandible: a reviev« of 580 cases, J Oral Maxillofac Surg 40:23, 1982.)

FIG. 24-11 Anatomic distribution of mandibular fractures. (From Olson RA et 0/:
Fractures of the mandible: a reviev« of 580 cases, J Oral Maxillofac Surg 40:23,
1982.)

FIG. 24-12 Types of mandible fractures classified according to extent of injury in area of fracture site. A, C-eenstick; 8, simple; C, comminuted; and D, compound.

FIG. 24-12 Types of mandible fractures classified according to extent of injury in area of fracture site.
A, C-eenstick; 8, simple; C, comminuted; and D, compound.

describes mandibular fractures by· anatomic location. Fractures are designated as occurring in the condylar, ramus, angle, body, symphyseal. alveolar, and rarely coronoid process areas. Fig. 24-]] llIustrates the location and frequency of different types of mandibular fractures.

FIG, 24-13 .Favorable and unfavorable fractures of mandible, A, Unfavorable fractures result4ng in displacement at fracture site caused by pull of masseter muscle. B, Favorable fracture in which direction of fracture 'and angulation of muscle pull resists displacement ..

FIG, 24-13 .Favorable and unfavorable fractures of mandible, A, Unfavorable fractures result4ng in
displacement at fracture site caused by pull of masseter muscle. B, Favorable fracture in which direction
of fracture ‘and angulation of muscle pull resists displacement ..

Fractures of the mandible are referred to as favorable or unfavorable, depending on the angulation of the fracture and the force of the muscle pull proximal and distal to the fracture. In a favorable fracture, the fracture line and the muscle pull resist displacement of the fracture (Fig. 24-13). In an unfavorable fracture, the muscle pull results in displacement of the fractured segments.

CAUSE AND CLASSIFICAT!eN OF FACIAL FRACTURES

CAUSE AND CLASSIFICATION OF FACIAL FRACTURES

Causes of Facial Fractures
accidents are far more frequent in people who were not wearing ~estraints at the time of the accident . The major causes of facial fractures include motor vehicle accidents and altercations. Other causes of injuries include falls, sports-related :!~<‘i{I”l1t~. and work-related accldents.v’ Facial fractures resulting from motor vehicle.

Radiographic Evaluation

Radiographic Evaluation
After a careful clinical assessment of the facial area, radiographs should be taken to. provide additional information about facial injurles.? In cases of severe facial trauma, cervical spine injuries should be ruled out with a
complete cervical spine series (i.e., cross-table,’ odontoid, and obliques views) befote any manipulation of the neck. The facial radiographic examination’ should depend to. some degree an the clinical examinatian
and the suspected injury. Haphazard or excessive radiographic examination is generally not warranted. In the patient with facial trauma, the purpose of radiographs should be to. confirm the suspected clinical diagnosis,
obtain information that may not be clear from the clinical examination, and more accurately determine the extent of the injury. Radiographic examination should also document fractures from different angles or
perspectives.
Evaluation of midface fractures is generally supplemented with radiographic views, including Wato/s’ view, lateral skull vie,”, posteroanterior skull view, and submental vertex vlew-tl-Ig. 24-9). However, because of the difficulty of interpreting plain radiographs of the midface, more sophisticated techniques are generally «sed.
This often includes CT scans done in several pla”C’~ of space (i.e., axial and coronal) or infrequently threedimensional (3-D) reconstruction (Fig. 24-101.

 FIG 24-8

FIG 24-8

 

FIG 24-9

FIG 24-9

FIG 24-10

FIG 24-10

 

 

 

 

 

History and Physical Examination

History and Physical Examination

After the patient has been initially stabilized, as complete a history as possible should be obtained. This history should be obtained from the patient; however, because of loss of consciousness or impaired neurologic status, information must often be obtained from witnesses or accompanying
family members. Five important questions should be considered: (1) How did the accident occur? (2) When did the accident occur? (3) What are the specifics of the injury, including the type of object contacted, the direction from which contact was made, and similar logistic considerations? (4) Was there a loss of consciousness? (5) What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and malocclusion? A complete review- of systems, including information about allergies, medications, and previous tetanus immunization, medical conditlons, and prior surgesies should be obtained.

FIG. 24-2 Tracheostomy, and cricothyrotomy sites with landmarks for emergency surgical airway access.

FIG. 24-2 Tracheostomy, and cricothyrotomy sites with landmarks for emergency surgical airway access.

A neurologic examination of the face should include careful evaluation of all cranial nerves. Vision, extraocular movements, and pupillary reaction to light should be carefully evaluated. Visual acuity or pupillary changes
may suggest intracranial (cranial nerve II-or III dysfunction) or direct orbital trauma. Uneven pupils (anisocoria) in a lethargic patient suggest an i~tracranial bleed (sub-

FiG. 24-3 Periorbital ecchyrnosrs and lateral sUUCUIlJUlKtl>JIIH:1lion IIU;)l' J~;u(iatt!d witfl zygomatic complex fracture

FiG. 24-3 Periorbital ecchyrnosrs and lateral sUUCUIlJUlKtl>JIIH:1lion IIU;)l’ J~;u(iatt!d witfl
zygomatic complex fracture

dural or epidural hematoma or intraparenchvmal bleed I or injury .. ·\n avyrnmetric or .irregular (not round) pupil is most likelv 4,,’I~ed by a globe (ereball) perforation . .Abnormalltlcs of ocular movements 111ayalso indicate either central neurologic problems (cranial ncrv es III, 1\’,
or \’1) or mechanical restriction of the movements of the eye muscles, resulting from’ fractures of the orbital complex (Fig. 24-4). Motor function of the facial muscles (cranial nerve VII) and muscles of mastication (cranial
nerve V) and sensation over the facial area (cranial nerve V) should be evaluated. Any lacerations should be carefully cleaned and’ evaluated for possible transection of major nerves or dllcts,such as the facial nerve or’
Stenseri’s duct.

The evaluation Of the midface begins with an assessment of the mobility of the maxilla either as an isolated structure or in combination with the zygoma or nasal bones. To assess maxillary mobility, the patient’s head
should be stabilized by using pressure over the forehead with one hand, With the thumb and forefinger of the other hand, the maxilla is grasped; firm pressure should be used to elicit maxillary mobility (Fig. 24-6).

F!G. 24-4 A, 14-year-old patient with a left orbital floor fracture in upward gaze. B, Entrapment of inferior rectus muscle is the result of impingement in area of linear orbital floor fracture. In down gaze, patient is unable to rotate the left eye inferiorly

F!G. 24-4 A, 14-year-old patient with a left orbital floor fracture in upward gaze. B, Entrapment of inferior rectus muscle is the result of impingement in area of linear orbital floor  racture. In down gaze, patient is unable to rotate the left eye  nferiorly

Intraoral inspection should include an evaluation of areas of mucosal laceration or ecchymosis in the buccal vestibule or along the palate and an examination of the occlusion and areas of loose or missing teeth. These areas .should be assessed before, during, and. after manual manipulation of the mandible and midface. Unilaterai occlusal prematurities with contralateral open bites. arc. highly suspicious for some type of jaw fracture.

FIG 24-5 AND 24-6

FIG 24-5 AND 24-6

FIG. 24-7 Injury to nasoorbital-ethmoid (NOE) complex, which resulted in the displacement of medial canthal Ugaments and a widening of the intercanthal distance (i.e., traumatic telecanthus),

FIG. 24-7 Injury to nasoorbital-ethmoid (NOE) complex, which resulted in the displacement of medial canthal Ugaments and a widening of the intercanthal distance (i.e., traumatic telecanthus),

 

 

 

 

 

 

 

 

 

 

 

 

EVUALATION OF PATIENTS WITH FAICAL TRAUMA

Immediate Assessment
Before completing a detailed history and physical evaluation of the facial area, critical injuries that may be life threatening must be addressed. The first stein evaluar ing a trauma patient is to assess the patient’scardiopular,stability by ensuring that the patient has a patent airway andis adequately ventilated. Vital signs, including respiratory and pulse rates and blood pressure, should be taken and recorded; During this initial assessment (i.e., primary survey), other potentially life-threatening problems, such as excessive bleeding, should also be addressed. .Immediate measures, such as pressure dressings, packing, and clamping of briskly bleeding vessels, should be accomplished as quickly as possible. An assessment of the patient’s neurologic status and an evaluation of the cervical spine should be completed next. ‘forces severe
enough to cause fractures of the facial skeleton are often transmitted to the cervical spine. T11e neck “Should be temporarily immobilized until neck injuries have been ruled out. Careful palpatio of the neck to assess ssiblc
areas of tenderness and a cervical spine radiographic Series should becompleted as soon as possible.

Simply grasping, repositioning and stabilizing the mandible into a more anterior position may alleviate this obstruction. Placement of a nasopharyngeal or an oropharyngeal airway may also be sufficient to temporarily maintain a patent airway. In some cases, endotracheal.
intubation may be necessary. Any prosthetic. devices, avulsed teeth, pieces of completely avulsed bone, or other

FIG. 24-1. Posterior displacement of tonque and occlusion of upper airway resulting from bilateral mandible fractures.

FIG. 24-1. Posterior displacement of tonque and occlusion of
upper airway resulting from bilateral mandible fractures.

debris may; also contribute to airwav occlusion and must he removed immediately, .-\ny areas of bleeding should be quickly examined and managed with packing, pressure , dressings, or clamping .. -\11 excess saliva and blood must, be suctioned from the pharynx to avoid aspiration and laryngospasm.