Facial Injuries

ATTR 650

Case Study Quiz

• A baseball player waiting his turn on deck receives a direct blow to the upper row of teeth by a baseball bat being swung by the person next to him.– Short list of injuries

– Tx

– Referral

21

Case Study Quiz

• A 14 YO basketball player is struck in the nose by an opponent's elbow while grabbing a rebound. He runs to the bench holding his nose, which is now pouring blood.This is what you see after stopping the bleeding.(procedures to stop)– Short list of injuries– Evaluate, TX– Referral

2

1

Anatomy

• Facial Bones

• Teeth

• Soft tissue

• Ligaments

• Muscle

Facial Bones

• Frontal bone• Bony orbit - superior, inferior, medial and

lateral• Zygomatic• Nasal - external and internal (posterior -

ethmoid, vomer and maxillary)• Maxilla• Mandible

Facial bones

Anterior Posterior

Teeth

Soft Tissue

• Eye

• Ear

• TMJ joint– Mandible and temporal bone– Ligaments– Joint capsule– Meniscus between the condyle of mandible and

articular surface of temporal bone (concave articular fossa and convex articular eminence)

Nasal soft tissue

• Cartilage of the nose – external = lateral and alar cartilage– internal = quadrangular cartilage and

membranous septum which separates it from the alar cartilage distally

• Septum divides into 2 passages (2-4 mm)– Proximal half is skeletal - vertical plate of

ethmoid, vomer, & minimal portions of palatine and maxillary bones

Nasal anatomy

Nasal Anatomy

Facial Muscles

• Muscles of facial expression and mastication

• Eye muscles– Superior, inferior, medial and lateral rectus– Superior and inferior oblique m (move eye

superiorly & medially, inferiorly & laterally)

Facial Injuries

• Bony Orbit

• Zygomaticomaxillary complex

• Nasal

• Maxilla

• Midface

• Smash Fx

• Mandible

Bony Orbit

Bony Orbit Fx

Evaluation

Bony Orbit Fx

Tx

• Depends on the size of the defect and the amount of entrapment.

• In the absence of diplopia, even in extreme up gaze, no treatment may be indicated but is usually offered in large defects where there is concern about prolapse of orbital fat and subsequent enophthalmos or entrapped tissue with persisting vertical diplopia.

• Surgical repair is best carried out within 10 days of the injury.

Zygomaticomaxillary Complex

Evaluation & Tx

crepitus

• If zygomatic arch may see dimpling with bone intact

• If unstable repair right away

• Lift up and out as it snaps back in (intra or extra orally)

Nasal Fx

Pathophysiology

• Frontal force - Causes damage ranging from simple fracture of the nasal bones to flattening of the entire nose

• Lateral force - May depress only one nasal bone; with sufficient force, both bones may be displaced; can cause severe septal displacement, which can twist or buckle the nose; septal fragments may interlock, creating difficulty in reduction

• Superior-directed force (from below) - Rarely occurs; may cause severe septal fractures and dislocation of the quadrangular cartilage

Clinical Findings

• Epistaxis – Common in nasal fractures due to mucosal disruption

• Change in nasal appearance

• Nasal airway obstruction

• Infraorbital ecchymosis

for CSF fluid

Septal Hematoma

• Possibility of septal hematoma – gentle palpation reveals it is soft and compressible

• needle aspiration or vertical mucosal incision and drainage

• firm anterior layered gauze pack to keep the septal mucosa pressed firmly against the cartilage.

Septal hemotoma

Septal hemotoma

Evaluation• X-rays are controversial - studies have shown that

radiographs are not helpful in the diagnosis or management of nasal fractures. Old fractures, vascular markings, and suture lines can lead to false-positive results.

• CT scan is more useful to assess for other associated injuries, as well as extent of nasal injury. Because the nose occupies such a prominent and accessible position, careful examination is possible and may obviate any need for radiographic study.

• Photographs are useful for documentation and for comparison with pre-injury photos.

Tx

• Elevation of head and cold compresses• Closed or open reduction within 2 weeks of the

fracture. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury, before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned for approximately 7 days following the injury.

Tx

• Waiting at least 6 months to perform surgery allows fractures to stabilize and wounds to heal if Fx identified after significant bony healing has occurred.

• Post surgery – splints in place for 7-10 days when necessary.

• Simple closed reduction requires no packing. • If packs used - continue taking antibiotics to

avoid toxic shock. • The use of cold compresses for 1-2 days

reduces edema and discomfort.

Maxilla & Midface Fx

LeFort Fx

LeFort Classification

• LeFort I - transmaxillary Fx runs between the maxillary floor and the orbital floor. The floating fragment will be the lower maxilla with the maxillary teeth

• LeFort II - described as a pyramidal Fx because of its shape. Involves maxilla & nasal (MOI = downward blow to nasal area)

LeFort Classification

• LeFort III - Referred to as the craniofacial disassociation as the unstable fragment is the entire face. (A/P translation)– It involves the maxilla, bony orbit and nasal

bone as well as soft tissue– MOI is a considerable force which also

involves injury to the skull and brain– Use of CT scan to diagnose

Tx

• Open or closed reduction

• Incision and the use of plates or screws septal damage vitals

Smash Fx

• Severe comminution of the face

• Underlying skull injury

• Individual is often in unstable condition with other injuries involved

Mandibular Fx

Tx

• Close reduction– Wire teeth together for 8-10 weeks

• Open reduction– Expose bone, line up and plate with titanium

plates– Compress further by wiring teeth (arch bars and

wire together)

Mandibular Dislocation

Evaluation & Tx

alignment – bite teeth together crepitus swelling, bleeding, numbness, pain,

bruising movement inside jaw

• Open or closed reduction

Anatomy of the Ear

Ear Injuries

• Laceration of the external ear

• Auricular hematoma

• Otitis Externa - infection of external ear

• Tympanic membrane rupture – sudden change of air pressure caused by blunt

trauma– Direct blunt trauma

Dental Injuries

Chipped Tooth – Class I and II Fx

1 2

Tx

• Avoid cold or warm liquids

• Check for exposure of pulp

• Do not try to locate the chipped area

• Refer to dentist the next day

• Tooth can be capped or bonded for cosmetic purposes

for tooth vitality periodically

Fx – Class III, IV

• Splint, root canal, removal of tooth

Lateral Luxation, (Root canal for repair)

Avulsion

• Complete displacement of the tooth from its socket

Avulsion with possible Fx of maxilla

Tx

• Replant immediately if possible (within 30 min)• Transport medium

– A.       Hank's Balanced Salt Solution (H.B.S.S.) – B.       Milk – but could sour over time– C.       Saline – D.       Saliva (buccal Vestibule) – If none of the above is readily available, use water

• Never transport in gauze

Management of root surface

• 1.       Keep the tooth moist at all times. • 2.       Do not handle the root surface (hold tooth by

the crown). • 3.       Do not scrape or brush the root surface or

remove the tip of the root. • 4.       If the root appears clean, replant as is after

rinsing with saline. • 5.       If the root surface is contaminated, rinse with

H.B.S.S. or saline If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and/or gently brush off debris with a wet sponge.

Management of the Socket

  1. Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline.      

2. Do not curette the socket. 3. Do not vent socket. 4. Do not make a surgical flap unless bony fragments

prevent replantation. 5. If the alveolar bone is collapsed and prevents

replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position.

6. After replantation, manually compress (if spread apart) facial and lingual bony plates.

Suture soft tissue and splint

1. use orthodontic brackets with passive arch wire. Suture in place only if alternative splinting methods are unavailable. (circumferential wire splints are contraindicated.)

2. Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits.

3. Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).

4.  Home care during splinting period: no biting on splint, soft diet, good oral hygiene

Prevention and Protection – Molded Mouthguards

• Impression of mouth, thermoplastic material adapted over cast

Laboratory Pressure Laminated Mouthguard

• Laminate 2-3 layers of EVA – use of high heat & pressure