1. Facial Injuries
ATTR 650

2. 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 2 1

3. 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

4. Anatomy
Facial Bones
Teeth
Soft tissue
Ligaments
Muscle

5. Facial Bones Frontal bone
Bony orbit - superior, inferior, medial and lateral
Zygomatic
Nasal - external and internal (posterior - ethmoid, vomer and maxillary)
Maxilla
Mandible

6. Facial bones
Anterior
Posterior

7. Teeth

8. 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)

9. 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

10. Nasal anatomy

11. Nasal Anatomy

12. 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)

13. Facial Injuries Bony Orbit Zygomaticomaxillary complex Nasal Maxilla
Midface
Smash Fx
Mandible

14. Bony Orbit

15. Bony Orbit Fx

16. Evaluation

17. Bony Orbit Fx

19. 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.

20. Zygomaticomaxillary Complex

21. If zygomatic arch may see dimpling with bone intact
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)

22. Nasal Fx

23. 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

24. Epistaxis – Common in nasal fractures due to mucosal disruption
Clinical Findings
Epistaxis – Common in nasal fractures due to mucosal disruption
Change in nasal appearance
Nasal airway obstruction
Infraorbital ecchymosis
for CSF fluid

25. 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.

26. Septal hemotoma

27. Septal hemotoma

28. 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.

29. 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.

30. 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.

31. Maxilla & Midface Fx

32. LeFort Fx

33. 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)

34. 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

35. Open or closed reduction Incision and the use of plates or screws Tx
Open or closed reduction
Incision and the use of plates or screws
septal damage
vitals

36. Smash Fx Severe comminution of the face Underlying skull injury
Individual is often in unstable condition with other injuries involved

37. Mandibular Fx

38. Close reduction Open reduction Tx Wire teeth together for 8-10 weeks
Expose bone, line up and plate with titanium plates
Compress further by wiring teeth (arch bars and wire together)

39. Mandibular Dislocation

40. alignment – bite teeth together  crepitus
Evaluation & Tx
alignment – bite teeth together
 crepitus
swelling, bleeding, numbness, pain, bruising
movement inside jaw
Open or closed reduction

41. Anatomy of the Ear

42. 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

43. Dental Injuries

44. Chipped Tooth – Class I and II Fx1 2

45. Avoid cold or warm liquids Check for exposure of pulp 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

46. Fx – Class III, IV
Splint, root canal, removal of tooth

47. Lateral Luxation, (Root canal for repair)

48. Avulsion
Complete displacement of the tooth from its socket

49. Avulsion with possible Fx of maxilla

50. Replant immediately if possible (within 30 min) Transport mediumTx
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

51. 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.

52. 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.

53. 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

54. Prevention and Protection – Molded Mouthguards
Impression of mouth, thermoplastic material adapted over cast

55. Laboratory Pressure Laminated Mouthguard
Laminate 2-3 layers of EVA – use of high heat & pressure