BDS10024 Trauma 4 edit.pdf

BDS 10024 Maxillofacial Trauma 4 Aims & objectives Aims: The aim of this lecture is to detail the clinical, diagnostic and management aspects of alveolar trauma and traumatic injuries in pediatric and geriatric patients Objectives: On completion of this lecture, the student should be able to: • U...

BDS 10024 Maxillofacial Trauma 4 Aims & objectives Aims: The aim of this lecture is to detail the clinical, diagnostic and management aspects of alveolar trauma and traumatic injuries in pediatric and geriatric patients Objectives: On completion of this lecture, the student should be able to: • Understand the clinical manifestations and management of alveolar traumatic injuries • Understand the principles of management of alveolar trauma • Understand the implications of extremes of age on the management of maxillofacial trauma • Identify the different management modalities of maxillofacial trauma in pediatric and geriatric patients Dentoalveolar trauma Is defined as a fracture of the alveolar process which may or may not involve the socket of the teeth and may extend to the adjacent basal bone • Dentoalveolar injuries occur in pediatric, teenage, and adult populations • Contact sports and playground activities lead to most injuries. • Child abuse is a significant cause of dentoalveolar injury Diagnosis of dento-alveolar fracture Periapical / panoramic radiographs Cone beam CT may be used to assess dentoalveolar fractures Traumatic dental injuries Extrusive Luxation & avulsion is the displacement of the tooth out of the socket in a coronal direction ➔ severance of neurovascular and periodontal tissue Management: delicately placing the extruded tooth back in the socket and stabilize it with a nonrigid splint (composite wire splint) for ~ 2 weeks. Pulpal necrosis may develop necessitating endodontic treatment. Splint requirements : Pediatric Dentoalveolar Trauma Treating the primary dentition is dictated by the possibility of tooth bud injury, due to the buccal-occlusal position of the primary teeth relative to the permanent tooth bud Transmitting force to the developing tooth occurs in displacement injuries → interference with odontogenesis → enamel discoloration and/or hyploplasia Classification of alveolar fracture : Class I : fracture of an edentulous segment. Class II: fracture of a dentulous segment with minor displacement Class III: fracture of a dentulous segment with severe displacement Class IV: part of multiple connected fracture lines Fractures of the tooth-bearing part of the jaws should be reduced and immobilised. Fixation of fractured segments to adjacent teeth may be accomplished by: wiring, arch bars, acid-etch-retained composite splinting, orthodontic banding or cementretained acrylic splints Splinting is required for a minimum of 4 weeks. Minor alveolar fractures may be fixed by acidetched composite splints extending beyond the involved region More extensive alveolar fractures are fixed by monomaxillary fixation techniques (Essig wiring for eg) More extensive alveolar fractures are fixed by monomaxillary fixation (Essig wiring here) Left in place for around 4 weeks • Digital manipulation and pressure, along with rigid splint stabilization, will usually be sufficient in the closed technique. • Inability to freely reduce fracture segments may be due to root / bony interferences and will necessitate open reduction and fixation • Avoid removing teeth that are considered non-restorable and that are within the bony segment until the bony healing phase is completed Splint is left in place for approximately 4 weeks Pediatric maxillofacial trauma : Low-impact forces are usually absorbed by the child’s well-padded skin, elastic skeleton, and cartilaginous growth centres → trauma rarely causes fractures in children Highly osteogenic periosteum in children → early healing of a fracture & more extensive remodelling after bone union has occurred Internal fixation is better avoided to prevent injury of the erupting teeth buds. circum-mandibular, circumzygomatic, infraorbital, anterior nasal spine wiring is used for fixation instead. When internal fixation is necessary (severe displacement & malfunction) → careful application of plates and screw fixation unicortical on the thick cortical inferior border + arch bar stabilization is often the least traumatic and most stable option. / resorbable plates Minor degrees of malunion may be self-correcting / orthodontically treatable This margin of safety should not be used as an excuse for inadequate treatment Pediatric mandibular fracture Monomaxillary fixation using bucco-lingual splints may be used – fixed by circumandibular wiring →Restore original occlusion Pediatric condylar fracture: Avoid open reduction as it causes irreversible injury to the highly differentiated TMJ structure. May cause : growth disturbance, TMJ ankylosis, internal derangement of the TMJ, loss of posterior facial height, malocclusion. Open reduction is only indicated in the following cases: • Displacement into the middle cranial fossa • Unacceptable occlusion after a closed technique trial has failed • Avulsion of the condyle from the capsule • Bilateral fractures of the condyles with comminuted midface fractures 10- 14 days of partial immobilization with elastics will encourage soft tissue healing and limit the conversion of a minimally displaced fracture into a displaced one. While the range of motion will reduce the possibility of TMJ fibrosis/ankylosis Physical therapy is essential as followup in these cases. Resorbable plates have been introduced primarily for pediatric internal fixation: Advantages : • No interference with growth • No need for second surgery to remove the plate • Does not affect the developing teeth buds • No interference with imaging (CT, magnetic resonance imaging, standard radiographs) • The possibility of integrating substances such as antibiotics within the material Disadvantages : • Less mechanical strength when compared with titanium alloys of similar sizes • “Memory” of the material, which may distort reduction of fracture • Increased reactivity during the degradation phase • Increased operative working time • Less mechanical strength when compared with titanium alloys of similar sizes Geriatric maxillofacial trauma: Implications of old age : - Complex medical conditions - Poorer healing capability due to aging - Increased bone resorption Treatment planning is influenced by: - Risks of prolonged surgery The impact on function from intermaxillary fixation Recovery from open surgery Poor healing capability Closed reduction with intermaxillary fixation will challenge the patient’s respiratory function & the ability to obtain adequate nutrition. Open reductions are a challenge to the patient’s cardiac, pulmonary, and wound-healing abilities. Fractures that are not optimally reduced and would normally heal uneventfully in a younger patient have a greater risk of fibrous union, nonunion, or prolonged healing. Management of fractures can also be more challenging because of edentulism. The patient’s use of partial or full dentures and their fit and condition affect treatment options. Bony changes in the geriatric population affect treatment choices: • maxillary bone is thin and fracture comminution is common. • atrophy of the basal bone as well. Among the most challenging fractures to manage are bilateral body fractures in the severely atrophic mandible. The patient with an edentulous jaws often has treatment compromised by thin bone and diminished bony volume in areas that might normally be used to secure a denture or splint Luhr’s classification for fractures of the edentulous atrophic mandible A direct relationship between the bony height at the fracture site and the rate of post-operative complications has been demonstrated De Feudis F, De Benedittis M, Antonicelli V, Pittore P, Cortelazzi R. Decision-making algorithm in treatment of the atrophic mandible fractures. G Chir. 2014 Mar-Apr;35(3-4):94-100. PMID: 24841687; PMCID: PMC4321595 Management of edentulous mandible fractures Closed reduction Geriatric jaw fractures have been managed with closed reduction techniques. ➔ did not fully reduce fractures & immobilization of the fracture was not complete Holes may be drilled in the easily repaired pink acrylic area of the denture to aid in securing arch bars to the denture, making stabilization to the underlying bone easier. If a denture is not available/usable, a Gunning’s splint can be fabricated Transalveolar wiring, transalveolar pin placement or suspension wires from the malar buttress , nasal spine, or zygomas are used to fix a gunning splint An anterior gap is essential to enable good feeding External pin fixation Used when open reduction is contraindicated for medical reasons or management of severely comminuted fractures or as temporary fixation Once external pins are in position, the fracture segments are manipulated to achieve reduction and the pins are locked in position by application of an acrylic mix on the ends of the pins that are protruding out of the skin Open reduction internal fixation ORIF The edentulous mandible with an adequate ridge is usually indicated for closed reduction with Gunning splints. More rigid fixation may be necessary in mandibles with less than 15 mm in bone height. To minimize subperiosteal stripping, many surgeons prefer to treat fractures with closed reduction techniques / open techniques that involve less periosteal elevation (eg.wiring or miniplate fixation) Spontaneous fracture Mandibles that have 5 mm or less of bone are at high risk of spontaneous fracture. Decreased bone volume ➔ decreased vascular supply from periosteum and endosteum ➔ decreased potential for osteogenesis ➔ compromised bony healing position of the inferior alveolar nerve on the ridge due to severe resorption may complicate internal fixation The use of larger plates, 2.4-mm mandibular fracture or reconstruction plates, and bicortical screws applied to an atrophic mandibular body fracture has gained acceptance as a technique that can best prevent the common problem of nonunion and fibrous union To minimize subperiosteal stripping, miniplates can be used A single miniplate may not be able to withstand the forces, so two mini plates should be used If there is not enough mandibular height, then reconstruction plate should be used If bone graft is needed, then reconstruction plate is used To sum it up …. • Restoring normal occlusion and range of maxillomandibular function is essential in management in any trauma condition • Dentoalveolar trauma is managed in one of several ways according to the case (composite splint / essig wiring / acrylic splint) • Pediatric trauma management should be done with care to avoid injury of the developing tooth buds • Edentulous jaws with an adequate ridge may be treated with gunning splints. More rigid fixation is needed in cases with insufficient bone height. Minimal periosteal stripping is crucial to avoid poor healing (wiring/miniplates) • Extremes of age effect healing differently and so management of children and old age patients differ Aims & objectives Aims: The aim of this lecture is to detail the clinical, diagnostic and management aspects of alveolar trauma and traumatic injuries in pediatric and geriatric patients Objectives: On completion of this lecture, the student should be able to: • Understand the clinical manifestations and management of alveolar traumatic injuries • Understand the principles of management of alveolar trauma • Understand the implications of extremes of age on the management of maxillofacial trauma • Identify the different management modalities of maxillofacial trauma in pediatric and geriatric patients. Further reading Students are advised to review any relevant teaching provided in the first year. In addition they are advised to read relevant sections of the following texts: 1. Wray D et al; Textbook of General and Oral Surgery, Churchill Livingstone 2003 pp 243-249 2. Coulthard P et al, Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine Churchill Livingstone 2003 pp 88-90 3. Hupp J et al. Contemporary Oral and maxillofacial surgery , Sixth edition 2014 4- Bourguignon C, Cohenca N, Lauridsen E, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and uxations. Dent Traumatol 2020;36(4):314-330. https://doi.org/10.1111/ edt.12578. Thank you