Surgery (TRAUMA) PDF

Habiba Tamer Aboelnaga MAXILLOFACIAL TRAUMA ** The aim of the treatment of any fractures is to keep the patient alive by life saving measures First Aid Treatment ➔ A= Airway management and cervical spine control (to avoid quadriplegia) ➔ B=Breathing...

Habiba Tamer Aboelnaga MAXILLOFACIAL TRAUMA ** The aim of the treatment of any fractures is to keep the patient alive by life saving measures First Aid Treatment ➔ A= Airway management and cervical spine control (to avoid quadriplegia) ➔ B=Breathing and adequate ventilation ➔ C=Circulation and shock management ➔ D=Drugs for control pain and infection (or disability of the pt) ➔ E= Exposure of the patient (bec. the pt is traumatized → expose the pt. to detect any blood or ay haga mstkhbya) (For complete examination of the patient by all consultants in different specialties.) Causes of airway obstructions 1. Falling back of tongue in unconscious patient (= blocked the airway→ suffocation) 2. Accumulation of blood clot in mouth and oropharyngeal region 3. Broken teeth, dentures, parts of jaw bone in oropharyngeal space 4. Obstruction by foreign body from the accident (same as no.3) 5. Regurgitation of the stomach contents (vomiting could be from eating or due to fracture of the base of the skull “will re-occur 2-3 post trauma) 6. Posterior displacement of tongue in bilateral parasymphyseal fractures (flail mandible) (anterior belly of digastric & genioglossus muscle→ flail mandible) ** Bilateral para-symphysis fracture (fatal) → Flail mandible → suffocation. 7. Maxillary fracture that cause the soft palate to fall on posterior part of tongue that cause obstruction To have clear patent airway treatment should be directed to!! 1. Positioning of the patient: post-tonsillectomy or prone position / supine position → put the pt’s head on a sandbag (to avoid falling back of tongue/ aspiration of regurgitation).. ➔ Shock position→ Trendelenburg position (rasie legs 30 and head 10 ) // passive leg raise (supine +raise his legs 45 degrees) ➔ In case of hemorrhage, position→upright. 2. Mouth clearance by suction if available, or swab with index for blood and secretion (To provide patent airway) 3. Tongue pull by finger, tongue forceps, stitch (very aggressive) 4. Push palate upward in cases with maxillary fracture 5. Jaw trust: by placing the hands behind angle of the mandible and push the mandible downward and forward (safest method) 6. Chin lift: by pulling the chin forward done by one hand 7. Nasal airway patent airway: by suction through nostrils to keep and 8. Oropharyngeal and nasopharyngeal airway that contraindicated in basilar or cribriform plate fractures (fracture of base of the skull)  Habiba Tamer Aboelnaga ** Oral airway → in case of fractured palate >> plastic (hard) hollowed tube placed (until it reaches the oropharynx → secure patent airway) ** Nasal airway → the tube applied is soft/rubbery → to protect the nasal airway. 9. Surgical airway: Tracheostomy: surgical creation of opening into trachea through the neck then insertion of tube to facilitate air passage to lungs (in case of ludwigs angina) Cricothyrodotomy: between cricoid and thyroid cartilages then connected to ambu bag or ventilator (press on it→ delivers air inside the trachea) 10. Cervical spine control: using head mobilizer or even sand bag (to avoid paraplegia or death) Breathing and adequate ventilation After assuring patent airway , breathes has to confirmed by look, listen, and feel If breath shallow, rapid spontaneous: supplemental oxygen If no breath: o Mouth to mouth breathing (gives 16% O2) o Face mask o Ambu bag (to mouth → gives 21% O2) o Ventilator (gives 100% O2) ** In case of no breath >> during the maneuver → the nose should be closed and sealed → to make sure that the air reaches the lung directly. Circulation and shock management Hemorrhage could be external (seen by naked eye) or internal (not seen by eye and it’s detected by ultra-sound) Internal hemorrhage like in abdomen as spleen or chest leads to hypovolemic shock (most dangerous) Hemorrhage from maxillofacial regions are from: Carotid artery and its branches Facial artery Superficial temporal artery Lingual artery Soft tissues >> soft tissue laceration. ** Fracture of mid-face: - Optic nerve → @ the apex of the eye >> hemorrhage >> stagnation→ blindness. - Vagus nerve → hemorrhage → bradycardia → syncope. - Retro-pupil hemorrhage → canthotomy @ lateral side of the eye. - Injury of oculomotor nerve and vagus nerve → affects the heart → Oculo-cardiac syndrome/syncope -because of retro bulbar hemorrhage or by infection → Meningitis → Death  Habiba Tamer Aboelnaga Control of bleeding Position of the patient Soft tissues laceration care (suturing) ➔ Continuous oozing of blood>> approximation of edges >> suturing. Major blood vessels ligation Anterior or posterior nasal packs (pressure packs) (in case of epistaxis) ➔ Pack is inserted inside the pt’s nose >> inject saline >> any bleeding will stop. Monitor blood pressure or skin perfusion test o Systolic B P 140 mm Hg…….blood loss not exceed 20% o Systolic B P 100-140 mmHg….blood loss 30% (TTT: Ringer’s lactate) o Systolic B P less than 100 mm Hg…blood loss more than 30% and patient needs blood transfusion. (otherwise→ neurogenic shock will occur) ** Suturing (muscle>> fascia>> skin) from inside to outside. ⁎ Skin perfusion test: Nail → Put pressure for 2-3 seconds → when blood returns after 3–5 seconds → No need for transfusion ⁎ Bleeding can cause death ⁎ Dec. B.P = Inc. blood loss. ⁎ If systolic is less than 100→ neurogenic shock. Shock (hypo-volemic shock) ➔ It is circulatory deficiency due to peripheral circulatory collapse, characterized by decrease cardiac output and haemoconcenterate. Manifestations of the shock: (hypo-volemic shock) Pale clammy cold skin Restlessness Face expressionless Disorientation Deep respiration due to air hunger Weak rapid thready pulse and decrease systolic pressure Treatment of the shock Place the patient in shock position (supine + raise his legs 45 degrees “passive leg raise”) Cover the patient with warm blanket Sedative and analgesics Oxygen supply Immobilization of the fractured jaw Replacement therapy e.g. fresh blood or blood substitute (saline/ringer’s/blood transfusion)) Corticosteroids e.g. Dexamethazone 1 gm IV (give norepinephrine & dopamine vasopressors)  Habiba Tamer Aboelnaga ** O2 supply >>> blood transfusion (severe cases) or give fluids (saline or ringer’s) Drugs for control pain and infection Local infection controlled by proper wound care Pulmonary infection controlled by prevention of aspiration and vomitus, blood, and mucous secretion (give antibiotic) Meningeal infection controlled by parenteral administration of suitable antibiotics that can cross blood brain barrier Tetanus infection by giving nonimmunized pt tetanus antitoxin (anti-titanic serum), and immunized pt a booster dose of toxoid Analgesics to control pain ** Skull base / middle cranial fossa fracture - Battle signs: o Raccoon eye o Ecchymosis at Mastoid process o Blood oozing from his nose/ears→ cerebrospinal fluid (cushing effect) ▪ CSF rhinorrhea → Watery and by test → Taste glucose or Gauze under patient’s nose ▪ If nasal discharge → it will become Dry ▪ CSF → Wait for 6–7 hours and sometimes it discharges from ears called otorrhea or forehead ▪ CSF → Biochemical analysis → +ve beta transferrin Disability and Neurologic Assessment ➔ AVPU: A: Alert V: Verbal P: Pain U: Unresponsive ➔ Glasgow Coma Scale: o Neurological scale to assess the level of consciousness after head injury o Patient assessed in points given in a score between 3 (Deep unconsciousness) and 14-15 (original scale) o If less than 8 no intervention (below 8→ no response) ⁎ Eye→ 4 ⁎ Verbal→ 5 ⁎ Motor→ 6 o Total: 15 - 3→ no surgery. - Above 8 → can do surgery  Habiba Tamer Aboelnaga Soft tissue injuries Contusion → due to blunt object trauma, pigmentation, subcutaneous o Type of hematoma→ Subcutaneous hemorrhage o No ttt just (Ice pack) Abrasion ‫ →سحجه‬very painful bec. the nerve endings are → exposed. o TTT→ disinfection by water & soap >> dressing Laceration → wound (bone exposed). o TTT→ suturing (muscle>> fascia>> skin) from inside to outside. Avulsion → Soft tissue o TTT: Small gap→ Undermining of tissues >> approximate and if large → free graft (flap from another area) Puncture→ due to knife or gunshot o Check inlet and outlet → should be seen. o Make sure that there’s no bullet/cartridge → If the puncture’s stable and away from vital structure → body will do epithelization and will get it out (in case of cartridge)  Habiba Tamer Aboelnaga Le fort maxillary fracture ➔ Le fort 1 (low transverse) aka Guerin fracture: o Floating maxilla (its horizontal >> alveolar bone with the maxilla) o Guerin fracture. ➔ Le fort 2 (pyramidal) → o Involving of nose, and infra-orbital nerve & margin. o Blindness may occur o Paresthesia of nerve. ➔ Le fort 3 (craniofacial disjunction)/ high transverse “very dangerous” o above nasal bridge reaching supra-orbital and zygomatic arch o Zygomatic complex fracture: zygomatic bone, arch & orbit. o Mid-face→ complete disjunction from cranium (Craniofacial dislocation) ▪ Retro-pupil hemorrhage (le fort 2/3) ▪ Exophthalmos ▪ Lateral canthotomy Mandibular anatomy Mandible from internal surface→ (mylohyoid line, mental foramen, submandibular fossa, sublingual fossa, mandibular canal) o Muscles on the internal surface→ mylohyoid, geniohyoid, & anterior belly of digastric) Mandibular fractures Fracture is the sudden loss of the continuity of that bone caused by a force beyond its normal physiologic limit (above its threshold) ** Vital structures related to the mandible→ bone, muscles (infrahyoid/ suprahyoid) ** Muscles of mastication→ - Temporalis→ attached to the coronoid process. - Lateral pterygoid→ attached to the condylar neck and disc. (helps open the mouth, imp. for protrusion→ pushing jaw forward). - Medial pterygoid → attached to the angle and ramus (helps close the mouth, lateral excursion) - Masseter→ lateral side of the ramus (in case of ramus fracture→ sandwich with medial pterygoid to ramus and angle→ reduction → tsbt ramus→ until healing/union occurs. ----------- - Genioglossus and anterior belly of digastric→ dislodgment/displacement in case of bilateral mandibular fracture/para-symphysial → flail mandible (suffocation could occur)  Habiba Tamer Aboelnaga Masseter - Origin: o Superficial head: Zygomatic process of the maxilla and the anterior two-thirds of the lower border of the zygomatic arch. o Deep head: Posterior one-third of the lower border and the medial surface of the zygomatic arch. - Insertion: Lateral surface of the ramus of the mandible, including the angle of the mandible. Temporalis - Origin: Temporal fossa of the parietal bone, frontal bone, and squamous part of the temporal bone. - Insertion: Coronoid process of the mandible and the anterior border of the mandibular ramus. Medial Pterygoid - Origin: Medial surface of the lateral pterygoid plate and the pyramidal process of the palatine bone. - Insertion: Medial surface of the angle of the mandible and the medial surface of the ramus. Lateral Pterygoid - Origin: o Superior head: Greater wing of the sphenoid bone (infratemporal surface). o Inferior head: Lateral surface of the lateral pterygoid plate of the sphenoid bone. - Insertion: Neck of the mandible and the articular disc of the temporomandibular joint (TMJ). Digastric (anterior and posterior belly) - Origin: o Anterior belly: Digastric fossa of the mandible. o Posterior belly: Mastoid notch of the temporal bone. - Insertion: Intermediate tendon that connects to the body of the hyoid bone. Mylohyoid - Origin: Mylohyoid line of the mandible (inner surface of the body of the mandible). - Insertion: Body of the hyoid bone and the midline raphe. Geniohyoid - Origin: Mental spine of the mandible (inferior mental spine). - Insertion: Body of the hyoid bone.  Habiba Tamer Aboelnaga Etiology of mandibular fractures Road traffic accident (RTA) (very common in egypt) Falls (1st / 2nd floor) Sports Blowing during fight (interpersonal violence) Wars Industrial accidents Gunshots Horse kicks or camel bites Pathological fractures(very imp) e.g. osteomyelitis, tumors or cyst e.g dentigerous cyst → detected accidently from a panoramic x-ray (and pt w23/due to extension of lesion in the bone/during eating >> mandible ytksr and no manifestation of this lesion→ pathological fracture) Road Traffic Accidents o High civilization → high injury o In car → fracture at mid-face o In lower socioeconomic (bike or motorcycle) → low injury→ mandible more than mid-face fracture. Sports injury ** Geriatric patients when they fall from stairs → fracture ** Young patient falls from 3 or 4th floor → small injuries and no fracture (bone→ has more elasticity, ossification didn’t occur yet) →Green-sticky fracture→ in children (fracture in side and bending of the other side) This is due to difference in elasticity of bone (Old age → more cortical bone and less spongiosa and cancellous bone) Fracture has a particular smell → debridement >> wash the pt’s face >> examination. Predisposing factors 1. Local factors: presence of impacted teeth, jaw cysts, tumors, and osteomyelitis (in bone) 2. General or systemic bone diseases: like hyper-parathyrodism, inc. in alkaline phsophates (general), renal osteodystrophy, and osteoporosis (systemic), marble bone disease (systemic) Large lesion cause fracture ➔ Classification >> management. ** Job of the patient→ plays a great role in the treatment decision.  Habiba Tamer Aboelnaga E.g; singer→ msh h2dr a2fl bo22o for 1-2 months , public figure→ m3mlsh scar in his face. Diagnosis → History >> clinical examination >> Investigation (X-ray)→panorama, submentovertix,..etc. If I suspected that the pt has a simple line of fracture→ panoramic film. Zygomatic arch fracture→ CT (gold standard), submento-vertix. ➔ Panorama→ pt presented with an (unfavorable) parasymphyseal fracture (if its due to direct trauma “mentioned” →automatically the other fracture site→ due to (indirect trauma” (referred fracture) ana el h2olha. → the referred fracture is condylar fracture. ➔ Guards stand for several hours>> vasovagal attack occurred→ symphyseal fracture/guard fracture occurs and it’s a Panoramic radiograph showing angle direct fracture. fracture due to presence of impacted lower third molar ➔ When there’s a direct fracture → suspect another line of fracture → indirect fracture. ➔ Direct trauma @the chin usually radiates @the condylar neck or angle of the mandible (indirect fracture) Classification of mandibular fractures According to site: o Anterior segment: ▪ Symphyseal → at midline of mandible between two central incisor → fracture→ 1 line. ▪ Parasymphseal →around symphyseal area → from central till canine >> forms 16% and it’s weak point >> long roots of canine o Body → From distal surface of canine till distal surface of 7 (fracture→ body fracture) >> 20-25% and its weak point→ mental foramen o Angle→ From distal surface of 7 till ramus, 20-25% and its weak point → lower 8 site) o Ramus→ one of the least common site of fracture (3%) o Coronoid→ fracture→ due to muscle contraction (temporalis→ fan-shaped→ attached to the coronoid so mn el khabta→ muscle contraction esp. if the trauma occurred while the pt. is opening his mouth) o Condylar→ most common site of fracture. o Dentoalveolar → horizontal, teeth are attached to the bone, 3-5%. ** Most common site of fracture→ @the condylar head/sub-condylar neck (30-35%) bec. the weak point @subcondylar neck. ** 2nd most common site of fracture→ angle ** Least common sites of fracture→ coronoid process (2%) and ramus (3%).  Habiba Tamer Aboelnaga ** Internal surface of mandible→ attachment of genio-glossus and genio-hyoid, mylohyoid groove (attached to the mylohyoid muscles → plays a great role in displacement of mandible during its fracture) ➔ Sometimes symphyseal fracture tdkhol fl middle cranial fossa (un-fav) ➔ Bilateral parasymphyseal fracture→ impairment>> suffocation (un-fav) ➔ Angle fracture>> comminuted>> displacement ➔ Most common fracture→ condylar head and least common (Dento-alv>> ramus>> coronoid “least”) II- According to nature of fracture/pattern: Simple→ aka sterile fracture (no communication with extra/intra-oral environment → no displacement >> just sharkh. o Fracture in ramus (stabilized by muscles from all sides), 1 line, o Fracture of condylar head>> kept in position and no communication. o In edentulous patients with incomplete fracture occluded by soft tissue and no teeth Compound→most of the fracture are compound. ➔ There is a communication either intra-oral or extra-oral)= high infection susceptibility (saliva=infection=abscess) o Dento-alv. segment (thru the socket) communication with extra/intra-oral environment Comminuted (mtdshdsh/crushed/splintered) → as puzzle/sugar particles → TTT by indirect fixation (periosteum and muscles → supports/stabilize it >> then its ttt. Green-stick→ most common in children (wall→ fractured >> other wall→ bending → due to the elasticity of bone) Complicated→ fracture of bone associated with injury to vital structure→ e.g nerve/vessels (fracture @the mental→ parasthesia/numbness or @the condyle→ tearing of parotid>> injury of salivary gland/blood vessel→ TTT: ligation. Complex → fracture of 2 different bones (e.g mandile and maxilla both)// zygomatic complex fracture //mandible+orbit. Pathological→ weakened by a lesion/cyst/tumor. III- According to no. of fracture lines Single Multiple (more than 1) IV- According to the side Unilateral (1 side) Bilateral (both sides) V- According to the relation between traumatic object and fracture Direct (trauma directly 3aleh) Indirect (referred fracture -> kan fi direct w da hasal b3do/nateg 3no.  Habiba Tamer Aboelnaga VI- Presence or absence of te eth Kazanjian classification (affects the prognosis) Fracture in patient with full component of teeth (class 1) “good prognosis” Fracture in a partially edentulous patient e.g @angle/pt with partial denture (side dentulous & side edentulous= class 2) “bad prognosis” (teeth=fracture=not teeth) Fracture in a completely edentulous patient (class 3) “very bad prognosis” VII- According to the degree of the (displacement = aw7sh haga t7sal) Vertical favorable fracture → outward and inward (medial pterygoid and lateral pterygoid) posterior and anterior (mylohyoid) Vertical unfavorable fracture→ outward posterior>> downward>> inward anterior (muscle pull ts7bo l gowa) Horizontal favorable fracture→ upward posterior >> downward anterior >> forward. Horizontal unfavorable fracture→upward anterior >> downward posterior >> backward parallel to muscle pull ** Degree of displacement → examined/known from clinical examination then x-ray. ** What decides (fav/ unfav)→ continuity of inferior boarder ** Occlusion is detected from a panoramic x-ray. ➔ Vertical view (axial/occlusal) = external/outward→internal/inward. ➔ Horizontal view (panorama/lateral) → parallel to the muscle (masseter and medial pterygoid)>> yshdha l fo2. (in the body of the mandible) ➔ Unfavorable → outward posterior >> inward anterior>> downward. ➔ Posterior view. ➔ Fracture is parallel to the muscle pull→ un-fav. ➔ If the fracture is oblique (3amodi) to the muscle pull → fav. ➔ The lower (position) of trauma→ low risk. ➔ The higher (position) of trauma→ high risk. ➔ Safety margin >> safety zone >> to not affect the middle cranial fossa>> brain concussion>> death.  Habiba Tamer Aboelnaga Factors affecting displacement of the fracture: 1. Direction of the fracture lines (outward/inward) 2. Direction of muscle pull (origin→ insterion // insertion → origin) 3. Presence or absence of teeth (Kazanjian c.1/2/3) 4. Direction and magnitude of force (trauma to the condyle→ displaced medially but if there’s a direct trauma on the condyle→ could be medially displaced or laterally displaced.) 5. Type of traumatic object (shakosh/edya/car/train accident) 6. Numbers of fracture lines. Diagnosis of mandibular fracture A. History → dental and medical B. Clinical examination → inspection and palpation “bi-manual or bi-digital using 1 finger” to check tenderness (in case of pain→ there may be condylar fracture) C. Radiographic examination → each part/area has a specific radiographic examination. Town’s view→ for condyle and condylar neck fracture Sub mento vertex→ for zygomatic process and zygomatic arch Panorama→ survey of the mandible CT→ gold standard which eliminates the use of any other x-ray in all types of fracture however it’s expensive and not always available. Or Lab. test → histology History Medical history (AMPLE) → conscious pt. o Allergies → Ab, sulfa. o Medications→ diabetic pt→ in case of tablets →ttt msh h2dr a2flo bo22o. o Past illness→ No epilepsy (convulsion attack >>lw aflt bo22o>> asphyxia) / cardiac disease/ any other disease. o Last meal→ akhr meal khdha → pt should fast before the GA by 6-8 hours>> shouldn’t drink water 4-6 hrs before the surgery to avoid vomiting during intubation (>> wana afla bo22o→ asphyxia/ infection of wound). o Events preceding trauma→ how did it occur? → e.g due to vasovagal attack so he felt suddenly on his chin → type of fracture: guard/symphyseal fracture → so to determine the ttt either closed reduction or open reduction. Mechanism of injury →is there any avulsed teeth/ presence of mandible/hasalet ezay. Date of trauma → e.g a week ago (concussion>> in a coma >>be non/mal-union of fracture will occur → deviation of mandible o TTT: Re-fracturing (to re-adjust it in its place) >> bone-to-bone contact >> occlusion: good alignment and intercuspation and the inferior border should be in harmony all around=m3 b3d. Site and cause of trauma  Habiba Tamer Aboelnaga Loss of conscious → should ask the pt if he lost his conscious during or after the accident → (loss of conscious = skull base fracture, brain concussion → CSF will dec. due to its leakage >> TTT: give antibiotic that crosses the BBB and close meningeal cavity by a neuro dr ) ** 4 tail bandage → in case of sudden accident e.g ala beach. Clinical Examination A. Extraoral inspection (by eyes) Facial orifices: eyes, nares, ears, mouth Facial deformities → any deviation. Areas of laceration , bleeding, or edema Racoon eye → ecchymosis, battle signs>> ecchymosis around the mastoid→skull base fracture Check: o Eye pupil Ocular muscles→ by 9-gaze test → by checking that the pt can move his eyes in 9 directions by placing my finger infront of the pt away from him 15 inch to detect muscles movement of the eye (extra-ocular muscles) → If there’s an orbital floor fracture then there will be stagnation/ trephination of the eye “muscle stagnates between the fractured bone segments and pt cannot raise his eyes >> muscle necrosis could occu and pt might die. Diplopia (double vision) → unbalance of pupil/orbital floor→> indicates its fracture. Retrobulbar hemorrhage→may cause blindness or pt might die due to oculo-cardiac syndrome. Facial deformity → deviation of mandible, laceration, bleeding, edema (indicates: fracture/contusion of that area) o Check pt picture/ take history before the surgery as for example if the pt is class III we won’t be able to do reduction to the mandible to normal class I” B. Extraoral palpation (by hands) >> bi-manual/bi-digital Examination→ from upward to downward by bi-manual (superior orbital rim to inferior orbital rim) check that its in good alignment >> no step >> zygomatic buttress >> bone>> zygomatic arch o In case of presence of pain= tenderness= fracture suspected → take an x-ray. o Inferior border→ crepitus voice due to bone-to-bone contact, step= fracture, edema Facial skeleton Areas of step deformity and tenderness Bimanual manipulation of the fractured segments ➔ Bi-manual manipulation→between 2 centrals→up/down, lateral and canine/ canine and 4/ @the angle→ medial and lateral no movement/ tongue→ moves in all direction and no  Habiba Tamer Aboelnaga laceration/ check by probe that there’s no sensory affection/ check that there’s/not step in the vestibule. C. Intraoral inspection Occlusion (check that there’s intercuspation) Presence of deviation during opening and closing Areas of bleeding , hematoma, edema (sublingual ecchymosis →most imp indicates mandibular fracture, ecchymosis in the vestibule also indicates mandibular fracture) Broken , avulsed, or chipped teeth o ecchymosis in vestibule → indicates fracture C. Intraoral palpation In vestibule for step deformity or tenderness Teeth mobility Bimanual manipulation of the fractured segments (palpate bi-digitally R/L/U/D → to check that there’s no step/discontinuity/pain/tenderness) ➔ Write all the findings in an informed consent ➔ Paresthesia → numbness → transient/permanent (lw fracture f part fi nerve 90% numbness will occur (if the pt stated that there’s numbness at lower lips→ (mental nerve involved) , lower side of his eye→ inferior orbital rim (infra-orbital nerve involved) Radiographic Examination I- Intraoral radiograph (@THE CLINIC) 1. Periapical radiograph → very accurate but only in the one-line fracture >> then do panorama after it to check whether there’s another line of fracture or not 2. Occlusal radiograph→ best type of x-ray to determine the symphyseal/guard fracture and symphyseal can be seen in periapical II-Extraoral radiograph (@THE HOSPITAL) 1. Panoramic radiograph→ To detect other lines of fracture 2. Posteroanterior radiograph 3. Lateral oblique radiograph 4. Modified Town's view 5. Sub-mento vertex 6. Sinus view 7. Computerized Tomography (C.T.) (GOLD STANDARD) Axial cut Coronal cut  Habiba Tamer Aboelnaga Reconstructive view (3D)→ shows condylar fracture/zygomatic arch/zygomatico- maxillary/ orbit Panoramic radiograph: ➔ Un-fav. Fracture: o It is a para-sympheseal fracture “open bite on one side and premature contact on the other side denoting a displacement. o There’s another line of fracture at the angle of the mandible “leave the 8 as it stabilizes the proximal and distal segments together unless this tooth is fractured or has a lesion around it then extract it” o Proximal segment> near midline o Distal segment> away from midline →so in case of un-fav fracture @the angle→ the distal segment fractures displace posteriorly >> superiorly by the action of the muscles o Panorama shows horizontal view ➔ When to extract the tooth→ if its broken with broken root, presence of periapical lesion Postero-anterior radiograph: ➔ Denoting angle fracture and symphyseal fracture (not the best type of x-ray to show symphyseal fracture) ➔ PA→ survey b kda then take another x-ray. Posterio-anterior Lateral Oblique Radiograph: ➔ Shows lateral fracture Lateral-oblique Town’s view: ➔ Best to show condylar head and condylar neck fracture ( TMJ) ➔ Sometimes → Modified town is used for elongation of ramus to show condyles clearly Sub-mento vertex: Town’s view ➔ Best to show zygomatic arch/zygomatic bone fracture ➔ In TTT →Zygomatic arch/bone fracture I need to restore→ function & esthetic. o Functional→limitation in mouth opening as the condyle gets stuck between the fractured zygomatic bone. o Esthetics→ due to flattening of the fractured zygoma. Sub-mento vertex  Habiba Tamer Aboelnaga →If zygoma is fractured and pushed inwards if the patient tried to open his mouth → restriction >>sometimes he can’t open his mouth as coronoid process can move as it must move anteriorly causes restriction. Sinus view: ➔ Best to show the superior/inferior orbital cavity fracture ➔ It shows the orbit only so cannot be used with any type of fracture. (doesn’t show floating maxilla/mandible→ not clear) Aim of treatment of mandibular fractures 1st aim→ to restore the pt’s life=keep the pt alive. 1. Restoration of function to the affected bone. - For the mandible, this must include: The ability to masticate food properly To speak normally To open the mouth as wide as before the trauma. 2-Restoration of any defect that may arise as a result of injury (contour). 3-Prevention of infection at the fracture site. FRACTURE HEALING ➔ If there’s bone to bone contact → Primary healing ➔ If there’s a slight gap between 2 fractured segments →callus formation (spongy bone>> osteocytes>> lamellar bone>> re-modeling>> form dense cortical bone → Secondary healing ➔ If zygoma is fractured and pushed inwards if the patient tried to open his mouth → restriction ,sometimes he can’t open his mouth as coronoid process can move as it must move anteriorly causes restriction Treatment of mandibular fracture Basic principles: - Reduction→ to restore the bone segments to the pre-injury anatomical shape/position - Fixation → by plates and screws. - Immobilization→ to prevent any micro-movement till healing occurs even in presence of plates→ so not to prevent or delay healing / cause delayed union. Healing: (Fixation/Immobilization period): - Children→ 1-3 weeks. - Adult → 6-8 weeks (45 days) - Old age (due to high bone density and less spongiosa → 8 weeks and more.  Habiba Tamer Aboelnaga Reduction ➔ It is the reposition of the two fractured bony segments into the preinjury normal anatomical position. Types of reduction: (affected by occlusion and bone) - Closed reduction: o Fracture is not seen by eyes, covered by mucosa/skin. o Minimal displacement. Reduction→ bimanual o Indirect fixation Fixation → by arch bars Immobilization → by IMF - Closed reduction by traction: o If the closed reduction failed to bring the teeth into occlusion and there was a space (when occlusion is affected). ➔ Put elastics between the mandible and maxilla which stimulates the fractured segment to move into occlusion. ➔ Why? As it counteracts the muscle spasm which initially displaced the fractured part - Open reduction (In case of malalignment after closed reduction to expose the fracture surgically to be able to see it and do proper reduction) a) Trans-mucosal (intraoral incision) → reduction till there’s bone-to- bone contact→ make sure that the teeth are in occlusion and intercuspation. b) Trans-cutaneous (extraoral) → multi-unit fracture/ bilateral/ un-fav fracture. -ve: affects the esthetics & injury to the marginal mandibular branch of the facial nerve could occur. c) Trans-buccal trocar (combination intra &extraoral)→ using trans-buccal retractor/trocar instrument Closed reduction Done bimanual In recent, with no or minimum displacement Guided by occlusion and alignment of inferior border ➔ Apply mandibular arch bar on the lower teeth and a maxillary arch bar on the upper teeth and pull them using a wire till reduction of the fractured segment happens + indirect fixation by the wire and the arch bar>> immobilization for the period mentioned before according to the age by MMF (maxillary-mandibular fixation)/IMF (inter-maxillary fixation) >> used in favorable/ minimally displaced fractures/minute interference with the inter-cuspation ➔ (Closed reduction >> indirect fixation >> immobilization)  Habiba Tamer Aboelnaga Fixation Maintenance and stabilization of reduced bony segments into normal anatomical position during healing period Types of fixation: I. Indirect fixation: in which the fixation hardware is applied away from the fracture line, always accompanied with closed reduction II. Direct fixation: in which the fixation hardware is applied directly on the fracture lines, done always with open reduction Types of indirect fixation Direct wiring o wire around the posterior tooth in both upper and lower teeth and attach these wires together → direct wiring between two segments of bone Ivy loop (eyelet loop) o Between kol 2/3 teeth bdkhal wire be tari2a mo3yana in mand and in max w b3mel loop w in this loop adkhal wire talet yrbothom be b3d→ IMF ➔ Arch bar→ IMF, Ivy loop→ WIRING, Screw→ IMF ** Direct wiring and ivy loops are obsolete nowadays ➔ we use IMF screw between two centrals in alveolar bone with a hole b7ot fe selk el hwaslo bl screw el t7t between centrals b7oto brdo 3nd premolar and molar areas → for immobilization. Arch bars o We insert wire in these hooks for immobilization and fixation o Hook looking upward in max, and downward in mandible. (ashan mytz7l2sh) Acrylic splints Cast metal cap splint Skeletal pin fixation → in case of communication/pathologic fracture. o Maxilla→ suspension→b3l2o al zygomatic arch → circum-maxillary. Disadvantages of the utilizing the intermaxillary fixation Affect the airway Interfere with speech Prevent accurate performance of oral hygiene measures Interfere with normal feeding Disturb the TMJ structures Subsequent muscle disuse atrophy Psychological impairment  Habiba Tamer Aboelnaga Splints (mono-maxillary fixation) (mono=in 1 arch only) ** used with children (CI to put plates/screws to not affect the unerupted/successors during mixed dentition (9-10yrs) Split Acrylic splint Circum-ferential/Circum-mandibular wiring (mandible) o Maxilla→ suspension→ (suspension wiring fl arch bar >> bn3l2 maxilla ala wiring) on the zygomatic arch/nose → circum-maxillary o Mandible→ circumferential/circum-mandibular wiring. →both are done in cases of mid-face fracture using bone owel. Splint with Circum-mandibular wiring GUNNING SPLINT FOR EDENTULOUS → curing the arch bar in the existing denture and stabilize it by circum-mandibular wiring or circum-maxillary suspension >> closed using IMF. External Pin Fixation/ Skeletal pin fixation → in case of communition/pathologic fracture→periosteum should be kept intact to prevent any infection or loss of blood supply. →2 rods are placed in distal segment and 2 rods in proximal segment then re-attach them together by acrylic resin/hadeda. Types of Direct Fixation → in case of multiple line fracture/ failed closed reduction→ bft7 aleh w ashofo b 3eny (Open flap is done to see fracture →either by trans-mucosal , trans- cutaneous or combination (intra and extra). 1. Non-rigid e.g. wire osteosynthesis→ closed using IMF. (not used bec. there’s micro- movement) 2. Semirigid e.g. miniplates, resorbable plate→ secondary healing as socket as there is micro- movement →callus formation → bone formation 3. Rigid → bone-to-bone contact → primary healing (angiogenesis of vessels>> bone formation from 2 segments >> 1ry healing bec. there's no any type of movement) Non compression plate Compression plate (CP) Dynamic Compression Plate (DCP) Eccentric Dynamic Compression Plate (EDCP) Reconstructive plate Lag screw ➔ -ve of rigid: o Presence of minute discrepancy in occlusion/mal-alignment → not ttt. o When the mandible is functioning → stress shielding phenomenon (plate t7t bone→ no fracture stimuli→ no bone formed→ non-union could occur). ➔ Sometimes due to minute movement→number of plates could be inc. Material used: - Titanium → best -Stain steel → corrosion and oxidation.  Habiba Tamer Aboelnaga Wire osteosynthesis (Obsolete as there’s high chance of movement in the fractured segments) Done by wires that pass-through holes that drilled mono-cortical in each segment of the fracture line >> immobilization for the stated period according to the pt age. (Healing→ 2ry healing) Consider nonrigid as it needs supplemental MMF Non rigid direct fixation (Straight wire /figure 8 / vertical line). Immobilization→ acc the the pt. age. Miniplates and screws (Mostly used) Semi-rigid (functionally stable fixation→ heals by 2ry healing – “granulation tissue formation>> callus formation>>woven bone>> osteogenesis>> lamellar bone>> remodeling>> union of fracture” as it must be supplied with short term IMF (7-10) days (to avoid micro-movement of fracture) “in case of public figure→ instruct them to not open their mouth, to not talk too much, to not eat hard food” o Made of st. st. or titanium >> adapt it using specific plyer >> it’s a little bit malleable. with different shapes and length (4,6,8,10, 16,….40-50 holes) ➔ Min. 2 holes right (In between the fracture) 2 holes left. (to prevent insertion of the screw into the fracture line)>> 2ry healing>> callus formation>> lamellar bone Plates fixed with screw have 2 mm diameter, but its core diameter is 1.5 mm to give stability (diameter of plate: 1.5-2mm and length of screw 5-15mm) Mono-cortical screws (5-7mm) are applied in superior border to avoid damage of the roots and inferior alveolar canal, while bi-cortical screws are applied in inferior border (10-15mm) → attached both lingual and external/buccal cortical plates of bone. (it won’t injure the nerve as it’s below it.) o 5mm → mono-cortical >>used in small diameters (e.g labial cortical plate of bone → to avoid injuty of roots or vessels.) o 10mm → bi-cortical (e.g in inferior border of the mandible. SEMI-RIGID: Placement of miniplates depends on Champy’s lines of ideal osteosynthesis Occlusal force on teeth→ compromization between teeth and mandible→ due to stability/stress distribution between force and muscle. o Tension→ due to muscle pull o Compression→ inferior border o Angle fracture→ put 1 plate on the external oblique ridge (mandible→ buttress bone→ longitudinal on the external oblique ridge with internal oblique ridge→ balance between muscles-→ masseter and medial pterygoid and temporalis→ re- establishment of stress distribution on mandible. (This is only used in fav- fracture/simple fracture)  Habiba Tamer Aboelnaga o In case of fracture in the body (canine→7) “tension zone”→ 1 mini-plate applied on superior border of the mandible. (to counteract tensile stresses). ▪ Screw used is monocortical → to avoid injury of root/inferior alv bundle/mental. ▪ Double length the length of clinical crown → then put the screw. o In case of un-fav fracture → put 2 miniplates→ (1→ external oblique ridge and another 1 on the inferior border→ could be applied using trocar (external and internal). o In case of symphyseal/parasymphseal fracture→ torsional force + it has more cortical bone (less vascularity >> delayed healing) → due to force action of the muscle (genio- glossus, mylohyoid and digastric) → 2 miniplates needed (1 in tension zone and 1 in compression zone) >> (start with the plate on inferior border >> then put the other plate on superior border). o In case of parasymphseal + unfav fracture + displacement → re-construction plate, rigid plate (this area has less vascularity/ delayed healing >> non-union could occur) o When applying a plate on the compression zone >> should apply another plate/arch bar on tension zone. **Champy’s principles: Superior border→tensile zone, inferior border→compression zone and natural zone in between. ** How do we apply the 2 plates? Extra-oral incision>> Using Kocher mosquito (holds the bone from proximal segment and distal segment) >> using cow forceps (agm3 bone) >> then put the plate on inferior border firstly, followed by the other plate on the superior border) → in case of parasymphseal or on external oblique ridge in case of unfav fracture. (In case of fav fracture→on the external oblique ridge longitudinally “2 screws above fracture and 2 screws below the fracture) - Symphesis: o Compression. o Tension. (put mono-cortical screw, a little bit malleable) o Torsional → due to genioglossus, mylohyoid and digastric nuscle. Champy’s lines of ideal osteosynthesis - Forces exerted on the mandible - Ideal osteosynthesis position Champy’s lines Definition : - Are those lines along which the plates and screws must be placed when treating mandibular fracture (fixation with miniplates is done ) to re-establish normal stress distribution in the mandible. PRINCIPLES OF FIXATION Using one plate with 4 holes for fixation In body and angle fr. 1 plate in tension zone  Habiba Tamer Aboelnaga Anterior to mental foramen put 2 plates to overcome torsional force in sympheseal and parasympheseal area. Unfavorable fracture usually needs 2 plates for good stability in two level. in champy lines due to strong buttress structure allow better fixation Miniplates MINI PLATES IN ANGLE MAND. FRACTURE (champy’s line) TRANSBUCCAL TROCAR → small incision in buccal tissues >> bdkhl zy masora >> drilling (in case of unfav) Resorbable bone miniplates - Made of poly-L Lactide Acid (PLLA) - Used with children → to not affect their growth, with pts on radiation - It is modified by warm saline-water. Advantages of resorbable miniplates ▪ Degrade with time: within 6 months. o Eliminate the need for a second removal operation o facilitate normal bone remodeling→ osteoconductive>> bone formation ▪ It can be used for fracture fixation when postoperative radiation is planned ▪ It is an osteoconductive → bone formation. Rigid fixation - Called functional stable osteosynthesis - No need for IMF (bec. there’s no micromovement) >> early immobilization, y2dr ytklm/yakol. - It depends on concept of the inclined plane (Gliding slope_ so produce horizontal movement of both fractured segment - It produce primary bone healing - Diameter of screws are (2.3,2.7 mm) Principles of osteosynthesis: - Early and active immobilization. - Anatomic reduction. - Stable fixation. - Preservation of blood supply. Associations of osteosynthesis/ American osteosynthesis (AO /ASIF) PRINCIPLE ASIF→ Association of osteosynthesis of inter-fixation  Habiba Tamer Aboelnaga Disadvantages of DCP 1. Needs extraoral approach (hard to manipulate it/ adaptation intra-oral) 2. Needs general anesthesia 3. Difficult plate adaptation 4. Any minor disturbance the surgery must be repeated (occ should corrected firstly) 5. Placed in compression zone (Tensile zone>> miniplate) 6. Must be accompanied with tension band at superior border Telescopic fracture→ bone overriding/overlapping on bone → fixed using rigid plate/ lag screw. ⁎ Rigid plates ⁎ Lag screws - Produce primary bone healing (bone-to-bone contact - Have threads in outer one third of screw - Core diameter is 2 mm, but thread diameter is 2.7 mm - The screw transfixes the oblique mandibular fracture, as when tightened it engage the bone only in the distal segment not in the fragment adjacent to screw head →First, drill in the bone >> insert the screw and start screwing the serrations of the screw will start lagging the bone →ys7ab bone w y2rab el bone el b3ed → it does rigid fixation to the distal part of the fracture 3shan bys7ab w yshed el distal part of the fracture (used in telescopic fracture/ condylar fracture/ fracture aadi/ sympshyseal → rigid fixation). Reconstruction bone plate - It is 2.7 mm titanium plate that give maximum stability - Used in cases of tumors resection, comminuted, non-united old fracture and pathological fractures - Used also in Distraction Osteogenesis (to form bone) - Used: in case of unfav fracture/ After resection surgeries of the mandible, we put it for 6 months then make sure there is no recurrent lesion/pathosis then do bone graft (from the hip/fibula). RIGID VERSUS MINIPLATES→ T.M.J ANATOMY →  Habiba Tamer Aboelnaga Complications of fracture: Plate exposure (dehiscence) Non-union → due to infection/ foreign body/ micro-movement. Delayed union → e.g in parasympseal area→ cortical bone, less vascularity. Mal-union → union but there’s discrepancy in occlusion/shakl Nerve injury→ paresethia. Question: Fracture and there is open-bite = unfav, unfav fracture in the angle of the mandible, parasympsheal unfav → 1- Arch bar and close using IMF (to get the occ back to its normal) then (we can use miniplates and screws intraorally “two miniplates with unfav fracture” (1→ tension zone, 1→ compression zone) Angle→(1 → external oblique ridge// 1→ lower border of the mandible as its unfav) both answers are correct but I must say the principles.. If the angle fracture was favorable we only put 1 miniplate at the external oblique ridge Types or classification of condylar fracture 1- Intracapsular fracture → inside the capsule, if not ttt well→ internal derangement, if the pt is growing → ankylosis could occur. 2- Extracapsular fracture (outside the capsule) a. high condylar neck→ @the sub-condylar neck b. Low condylar neck → @the sigmoid notch. 3- Unilateral or bilateral fracture 4- Condylar fracture with concomitant mandibular fracture→ ttt mandible 1st then ttt the condyle. 5- Condylar fracture with pan-facial fracture (fracture of condyle + mid-face) Clinical classification spiessl & schroll 1972 -Type I No Displacement (in position →no ttt, just follow-up) -Type II Fracture deviation (or slight displacement)→ ttt: follow-up + Arch bar>> IMF (7-10 days) to make sure the occlusion is back to normal (conservative surgery) - Type III Fracture Displacement (little displacement) → ttt: follow up + Arch bar>> IMF (7-10 days) to make sure the occlusion is back to normal (conservative surgery) - Type IV Fracture Dislocation → out of articulation. o ## Absolute indication for surgical intervention for condylar fracture→ ▪ condyle is entrapped into the middle cranial fossa. ▪ Foreign body (kartosha/bone) ▪ Direct trauma on the condyle >> displaced laterally. ▪ Derangement of occlusion.  Habiba Tamer Aboelnaga Condylar facture Classification of condylar fracture - According to the side: o unilateral o Bilateral According to capsule: o Extracapsular o Intracapsular According to displacement: o Anterior displaced o Medial displaced o Lateral displaced o Dislocated According to relation to trauma: o Direct condylar fracture o Indirect condylar fracture o Condylar facture ** In indirect or direct condylar fracture if the condyle is displaced laterally→ Absolute indication for surgical intervention. ** But if displaced medially due to the pull (lateral pterygoid and medial pterygoid) of the lateral pterygoid muscle no need for surgical intervention. According to the fracture level: o condylar head o Condylar neck o Subcondylar (high or low) CONDYLAR EXAMINATION - Clinical signs of condylar fracture o Extraoral: ▪ Swelling over the joint ▪ Blood/CSF in the external auditory meatus ▪ Deviation of chin in unilateral fracture ▪ Tenderness on palpation and during mouth opening ▪ Inability to palpate condylar movement ▪ Limited range of motion - Ask the pt to open his mouth >> If the dr is feeling the condylar movement→ no fracture, in case of no movement→ fracture.  Habiba Tamer Aboelnaga o Intra-oral: 1. In unilateral fracture there is malocclusion (premature contact in the ipsilateral/affected side and open bite in the contralateral/other side), and shift in the midline ** Deviation to the mandible towards the ipsilateral/affected side/side of fracture + premature occlusal contact in the affected side and open bite in the contralateral/unaffected side 2. In bilateral fracture there is COMPLETE anterior open bite with normal occlusion posterior (relative indication surgical intervention) 3. Teeth fracture: palatal cusps of upper and buccal cusps of lower teeth Radiographic Examination 1. Panoramic radiograph: showing empty fossa and increase in joint space 2. Modified Town's view: showing elongated condylar fracture 3. Coronal CT: important in sagittal fracture of the condyle. ➔ Deviation towards medial side>> examination: open bite, lw amlt force→ occlusion. o →decrease in vertical dimension →shortening of the face so it’s relative indication for surgical intervention o Follow-up→ condyle stability due to pseudo-joint. o Never azabat occ in 1 side (esp in young age I should correct both sides). ➔ In case of ankylosis→ I remove condyle khales (space) >. Replaced by condylar prosthesis. ➔ Fracture in middle cranial fossa (ab3d condyle→healing),, fracture in glenoid fossa. Goals of therapy 7. To get stable occlusion 8. Restoration of interincisal opening (no open-bite) 9. Full range of mandibular excursive movement 10. Decrease deviation 11. No pain 12. Avoid internal derangement 13. Avoid growth disturbance  Habiba Tamer Aboelnaga ➔ No ttt→ no occ discrepancy → just follow-up. ➔ Closed reduction (when occ is affected)→ arch bar>> IMF ,, Cap splint (in case of baby “no teeth’’) ➔ Open reduction. Treatment of the condylar fracture Short term immobilization (MMF) 7-10 days followed by muscle rehabilitation program i.e. closed method except some cases which need open reduction and internal rigid fixation I- Absolute indications: ➔ Limitation of function secondary to: o Fractured in middle cranial fossa o Foreign body in joint capsule o Lateral extracapsular dislocated condyle o Other dislocated fracture that produce mechanical stop during opening (other type of fracture→ zygomatic arch fracture) ➔ Inability to bring the teeth into occlusion by closed reduction. II- Relative indications: o Bilateral condylar fracture with comminuted midface fracture o Contraindication for MMF e.g. medical compromised o Bilateral condylar fracture o Dislocated condylar fracture (completely dislocated laterally blzat)  Habiba Tamer Aboelnaga EXTRA ORAL APPROACH: - Endaural incision (high esthetics→msh btban >>comes out the ear canal towards the temporalis) - Peri-auricular flap - Retro-mandibular (behind the joint) - Submandibular approach. Recent types and shapes of miniplates used for internal fixation of condylar fracture Postoperative care 1. Immediate postoperative care: - Postoperative vomiting - Respiration and signs of obstruction - Patient position and wire cutter 2. Intermittent ice packs in area of surgery (to avoid edema and dec. inflammatory process) 3. Medications: antibiotic, analgesics, and sedative (cerelac, high protein content, soft food) 4. Feeding (using a straw) 5. Oral hygiene measures 6. Follow-up Complications of fracture 1. Plate exposure 2. Delayed union 3. Non-union 4. Malunion 5. Infection 6. Nerve injury 7. Ankylosis “” Be grateful and never take anything for granted! “” Good luck,, Habiba Tamer Abo-elnaga  Habiba Tamer Aboelnaga Cases in the ppt