Facial Trauma Flashcards
most common etiology of facial trauma
43% vehicular accidents
34% assaults
7% work related
7% fall
4% sporting
5% miscellaneous
most common mandibular fracture location
condyle 29.5%
- shape implicaton
symphysis 22%
body 16%
alveolar 3.1%
ramus 1.7%
coronoid 1.3%
body 16%
classification of mandibular fractures
displaced (doesnt stay in position) or undisplaced fracture
- location
- direction of the line of fracture
- direction of the muscular forces
horizontal favorable or unfavorable
vertical favorable vs unfavorable
neurological examination
cranial nerves examination
II- optic III- occulomotor IV- trochlear V- trigeminal VI- abducens VII- facail
mandibular fracture by type
simple or closed
compound or open
simple or closed mandibular fracture
a fracture that does not produce a wound open to the external environment, whether it be through the skin, mucosa, or periodontal membrane
compound or open mandibular fracture
a fracture in which an external wound, involving skin, mucosa, or periodontal membrane, communicates with the break in the bone
comminuted mandibular fracture
a fracture in which the bone is splintered or crushed
- like gun shot
greenstick
a fracture in which one cortex of the bone is broken, the other cortex being bent
- INCOMPLETE
pathologic fracture
what to note
a fracture occuring from mild injury because of pre-existing bone disease
LOOK FOR EDENTULOUS ARCH – may be more likely to be pathologic if less bone present
- different than injury - something going on before
- like pre-exisitng patholgy - cyst tumor cancer, osteonecrosi, etc
radiographic examination of mandible series
LEAST PREDICTABLE
- towne’s view
- anterior - posterior view
- lateral oblique right and left
panorex use
most common
most predictable radiographic examination uses
CT scan
general principles of fracture treatement
reduction
stabalization
fixation
rehabilitation
4 types of overarching fractures
mandible fractures
lefort fractures
zygomatic complex fractures
naso-orbital ethmoidal fractures
treatment of mandible fractures
objectives
re-establish
OCCLUSION
open bite suggestive of
fracture
primary objective of treatment of mandibular fracture
OCCLUSION then restore the form and function
common indications can do closed reduction tx
non displaced favorable
grossly communicated fractures
deficient or lack of overlying soft tissues
fractures in children with developing dentition
cornoid process fractures
majority of condylar fractures
physical examination should include
- general examination
when, where, etc - soft tissue
- lips, cheeks, etc - neurologic examination
- facial injury in combination with brain injury - cranial nerve checking - bony examination
- ocular examination
right side under the ear - what other structures should you think of?
facial nerve – 5 terminal branches
parotid gland – + the duct
facial artieries
bony fractures broken down into
- mandibular
- lefort fractures
- zygomatic complepx fractures
- naso-orbital ethmoidal fractures
muscle and fracture pattern
pull of muscle - may
displace fracture - take fracture away = displaced
sometimes muscle pull – brings fragments closure – favorable
if muscle pull
masseter on buccal and medial pterygoid on lingual?
fracture pulls up
pterygo-masseter SLING
if ledge of bone above – FAVORABLE -
horizontally favorable
no superior ledge of bone and fragment travels posterior and DOWN - leaving unsupported bone
sling is free
horizontally unfavorable
displaced or undisplaced fracture gets further catagorized into
location of the fracture
direction line of the fracture
direction of the muscular forces
if looking at a fracture in a PANO - what orientation
horizontal aspect
muscle pull together brings fracture fragment UP with no superior ledge of bone
horizontally unfavorable
no superior ledge of bone
fragment piece may go posteriorly DOWNWARD
- and then with no superior ledge of bone the masseteric and medial pterygoid together pull the fragment superiorly unopposed
horizontally UNFAVORABLE
looking at a fracture from below or from the top will catategorize it as
vertically favorable or unfavorable
medial pterygoid sling on the lingual - but no muscle pulling it buccally - but buccal bone present
vertically FAVORABLE - muscle alone cannot displace it
fragments wont get displaced
no buccal or lingual bone ledge looking from the top
vertically unfavorable
the medial pterygoid muscle can pull the fragment and displace it
reduction to happen
need minimal displacement to happen
simple =
closed
compound =
open
Which locations of mandibular fractures do you think would be involved with simple/ closed or compound/ open fractures?
coronoid or condyle in isolation may be simple
other areas — teeth involved
- pdl space – considered a point of entry - compound / open fracture then
picture of radiograph with pano showing left mandibular fracture and asked to classify it
- looks completely broken
- no teeth
good example of PATHOLOGICAL FRACTURE
- mandible gets weak and then completely fractures
x-ray shows displacement of the mandible superiorly
horizontally
altered sensationo of lip?
inferior alveoolar canal affected
- can get pulled with displacement
intra oral picture suggesting mandibular fracture - what to note
BREAK IN GINGIVA
OCCLUSAL STEP
open bite
sublingual hematoma or ecchymosis
open bite?
suggestive of mandibular fracture
pathonemonic for mandibular fracture
floor of the mouth ecchymosis
sublingual hematoma
panorex with radio graph exam
mot common
CT scan rx use?
most predictable
mandible series?
- towne’s view
- anterior - posterior view
- lateral, oblique, right and left
LEAST PREDICTABLE
general principles of fracture treatment
- reduction
- stabilization
- fixation
- rehabilitation
primary objective in tx of mandibular fractures
RE-ESTABLISH OCCLUSION
then form and function *
types of treatment for madnibualr fractures
- no treatment / liquid diet
- closed reductiono
- open reduction (most complicated - exposing the sites and re-aligning)
two mandibulr areas that can likely be treated by closed reduction
- coronoid – not going to invasively go into the mandible and ‘hunt down’ this area
MAJORITY of condylar
best indication to do closed reduction
have a non displaced favorable fracture
tx of comminuted fractures
closed reduction
if try and get all pieces and put togethre- may strip off periosteum which is the life of the bone
closed reduction tx modalities
- ivy loops
- arch bars
- splints
- gunning splints
- denture
- lingual splints
- cap splint - external pin fixation
- most unsightly form of
arch bars basiclaly
bar on top and botoom
hold them together
intermaxillary fixation
- get teeth righ t– to then hold bone to the right place
Mand F
maxillary and mandibular arch fixation
capping splint
closed reduction tx technique
pass wires over and under
- NO TEETH
- need another area for fixation
dentures used in tx?
yes for mandibular fixation with denture – closed technique
modify the existing denture to hold onto the bars
external fixation
bar around all of the mandible with screws fixated in
tx modalities for open reduction - general
non rigid fixation
semi rigid
rigid fixation
arch bar splints can use
patients denture
example of non rigid fixation - include type of tx
for mandibular fracture - OPEN REDUCTION
- WIRES
example of semi-rigid fixation - include type of tx for
for madnibular fracture - tx by OPEN REDUCITON
- MONOCORTICAL SCREWS/PLATES (CHAMPY)
wires in open reduction example of
non rigid fixation tx
monocortical screws/plates tx for
semi-rigid fixation uses open reduction
tx for mandibular fractures
compression plates and reconstruction plates used in
open reduction rigid fixation treatment for mandibular fracture
rigid fixation for open reduction tx options
compression plates and reconstruction plates
not really used as much but much thicker
examples of mid face fractures
- lefort I,II, III
- zygomatic complex fracture
- zygomatic arch fracture
- naso-orbital ethmoidal fracture
lefort I
horizontal fracture
over apices of maxillary teeth
lefort II
pyramdal fracture
goes more superior
crosses zygomatic maxillary suture
on orbital floor
along the nasal frontal and maxilo-frontal suture
shape – triagular / pyramidal
lefort III
goes even more superior than the lefort II
zygomatic arches and frontal zygomatic suture - more lateral
maxillary boe separted from cranium bone **
craniomaxillary dysjunction fracture
zygomatic complex fracture
outside of orbit – look at slide picture
patient will present with zygomatic ecchymosis and edema
lateral eye and where zygomatic bone - frontal bone come together too
from view below can see the disjunction of zygomatic arch
from view below can see the disjunction of zygomatic arch
ZMC complex fracture
most common symptoms for midface fractures
KNOW this
1. pain, edema, and ecchymosis of cheeks and eyelids
- malar flattening
- step defect at INFRAORBITAL SUTURE
- step defect at FRONTOZYGOMATIC SUTURE
- TRISMUS
Occlular eye exam important in
all really but with midface fractures may find
- infra-orbital nerve parasthesia or anesthesia
- enopthamlmos (posterior displacement of eyeball) or proptosis (protrusion of eyeball)
- diplopia (double vision)
- decreased mobility of extra ocular muscles (upward gaze)
ZMC cranial nerve examination
same as others CN II CN III CN IV CN V CN VI CN VII
(2-7)
scan of choice for midface fractures
CT scan
imaging facial series for midface fractures
plain film
submental-vertex view
townes, AP views
Waters View
CT scan with ZMC fracture
sinus will look all grey because of the inflammation
- bones fractured to fluid and edema gets in
normally should be all black
typically appearing like a v
TRISMUS
fracture of zygomatic arch
trismus a sign for
zygomatic arch fracture
