MAXILLOFACIAL TRAUMA
LEARNING OBJECTIVES:
1. That students understand the correlation between intensity of injurious force and the
extent and severity of tissue damage, including serious, occult systemic injuries.
2. To familiarize the students with normal bone healing.
3. That students are able to apply the principles of patient management AND normal
bone healing to the management of various dental, dento-alveolar or jaw injuries.
A. INJURIES
1. Tissue Damage: Acute application of excessive force to the tissues of the face
results in tissue damage. This damage is related to the magnitude of the force
and to the site of force application.
2. The magnitude of force application can usually be correlated to the nature of
the circumstances surrounding the injury. The following injuries roughly
correlate with tissue damage in increasing order:
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simple falls
punch in the face
sports injuries ( puck in the face )
kick in the face
assault with a blunt object ( baseball bat )
bicycle accidents
car accidents
motorcycle accidents
train wrecks
3. Site of the injury: the tissues that may be damaged in an injury include:
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Skull / brain and vertebral column / spinal cord
Larynx and trachea
chest wall and lungs
heart and great vessels
liver, spleen, GI tract
pelvis, kidneys, bladder
long bones: femur, humerus, etc
soft tissues of the face: scalp, skin, muscle, nerve, mucosa, etc
facial bones
teeth
4. In the area of the jaws …
Soft tissue injuries include: abrasions, contusions or lacerations.
Bone injuries include: dental avulsions, single tooth alveolar fractures, segmental
alveolar fractures, body fractures or ramus / condyle fractures. As far as bone injuries
are concerned, not all sites in the facial skeleton are created equal. The condylar neck is
quite slender and weak. In contrast, the mandibular symphysis is very dense and strong.
The greater the force of the injury, the more extensive will be the damage with respect to
distribution (multiple fractures) and severity ( comminution ).
Dental injuries include: cracks, enamel chips, fractures through enamel and dentin, pulp
exposures or root fractures.
All of the above may be combined in any given patient. Combinations are more likely as
the force of the injury increases.
B. NORMAL BONE HEALING:
The initial event in normal bone healing following fracture is bleeding followed by
the formation of a blood clot in the fracture site and the initiation of inflammation.
The clot forms in and around the ends of the fractured bone, torn periosteum and
displaced soft tissues ( such as muscle ). The clot forms the matrix or scaffold for
future bone healing.
Inflammation with the transudation of fluid, increased in blood flow and release of
various mediators ( such as prostaglandins, bradykinins, etc.), result in the swelling,
redness, heat pain and loss of function associated with injury. These inflammatory
effects are demonstrable in the jaws as swelling, pain and trismus. Within days,
endothelial in-growth along with macrophages and fibroblasts results in elimination
of the original clot and replacement with granulation tissue rich in blood vessels
and collagen. This new collagen network forms the matrix for initial bone
deposition and the formation of a woven bone primary callus.
By four to six weeks, this callus reaches a level of “ strength” of approximately 30
to 40% of the ultimate strength of the fully healed bone ( which occurs by six to
twelve months ). With time, the bone remodels in response to physiological
stressed ( exerted by muscles ) and resumes the normal configuration of
periosteum, cortex and trebecular bone.
Stability relates to normal bone healing during the fixation period. The main
consideration in stability is resistance is forces generated by muscles. If fixation is
inadequate, muscle forces can distract the segments and result in malpositioning of
segments. This can lead to either localized sepsis, malunion or non-union. During
the six weeks of fixation, the wires hold the bones in position while initial callus
formation occurs. By six weeks, the bones usually have enough strength to resist
muscle forces on their own and the wires can be released.
C.
HISTORY, EXAMINATION, RADIOGRAPHS AND DIAGNOSIS:
1. History
 where is the injury (where does it hurt?)
 how did it happen....nature of the force
 when did it happen
 loss of consciousness
 neck, chest, abdominal, limb problems
 bleeding
 contamination (eg. road rash)
 tetanus status
 areas of numbness (nerve damage)
 medical history
2. Examination
 extra-oral
orbital rims
zygomatic arches
condylar areas
body of mandible
note bleeding, ecchymosis, swelling, tenderness
 intra-oral
loss of teeth or parts of teeth
lacerations, bruising
occlusion
step defects
obvious mobility
3. Radiographs: (intra- and extra-oral films +/- CT scans)
 x-ray (image areas of concern with 2 films at 90o to one another: eg. periapicals & 90o occlusal )
gaps
overlap
lost teeth
displaced teeth
foreign bodies
chest x-ray to locate missing pieces
4. Diagnosis: a list of the injuries:
Systemic injuries: airway, cardiovascular, Intracranial, abdominal, etc
Osseous injuries: displaced right mandibular angle fracture and condylar neck fracture
Dental: avulsed tooth #11, palatal luxation of tooth #21
Soft tissue: 1 cm labial mucosal laceration lower right, facial abrasion
D. TREATMENT PLANNING:
Priorities:
Airway / Breathing / Circulation / Disability: maintenance of an intact airway,
control of serious bleeding and prevention or management of cranial or neck
injuries are obviously the first priorities on an emergency basis. Having managed
these problems or determined that these are not issues, management can now
proceed to the jaw problems.
Tetanus status: must be determined and tended to either through active (tetanus
booster) or passive (tetanus immune globulin) immunization
Restoration of function: 3 main principles of fracture management
i. reduction: return of a displaced part to its original anatomical location
ii. fixation: ligation of the displaced part to adjacent non-fractured structures
iii. immobilization: stabilization of displaced parts to prevent movement during healing
Steps:
1. Informed consent: regarding options with respect to treatment (for example
extraction versus splint, endo, post and core and crown), includes duration of
treatment, costs, sequelae and complications as well as patient expectations
(maintenance of a soft diet, avoidance of sports, etc)
2. Intra-operative pain control: local vs. sedation vs. general anaesthesia
3. Prevention of sepsis: pre- and post-op antibiotics, wound prep solutions,
debridement of foreign debris and necrotic tissue. OHI
3. Reduction, fixation and immobilization of injuries in sequence: reduce and fix
dental injuries, reduce and fix bone injuries and then repair soft tissue injuries last so to
avoid damage to sutures while manipulating teeth and bones. By the selective application
of the principles of reduction, fixation, and immobilization, normal bone healing is guided
by the clinician. The clinician’s aim is to restore the fractured parts to their original form
and function. Understanding of the processes of bone healing allow the clinician to
understand the need for minimal movement when bone to bone healing is required. In
contrast, management of the dental avulsion is dictated by the need to prevent ankylosis
from occurring. From this point of view, the avulsed tooth needs to be removed from
fixation at approximately two weeks in order to allow for “physiological stimulation” and the
formation of a fibrous union only in the area of the PDL.
4. Post-op Medications: analgesics, antibiotics, mouth rinse, etc
5. Follow up: during the period of fixation, release of fixation, long term restorations
The Glasgow Coma Scale (GCS):
A. Eye opening
Spontaneous …………………… 4
To speech ……………………… 3
To pain ………………………….. 2
None …………………………….. 1
B. Best verbal response
Oriented ………………………… 5
Confused (conversation) ……… 4
Inappropriate (words) …………. 3
Incomprehensible (sounds) …... 2
None …………………………….. 1
C. Best motor response
Obeying (follows commands) … 6
Localizing ………………………. 5
Normal flexion …………………. 4
Flexing (abnormal posture) …… 3
Extending (abnormal posture) .. 2
None (no movement) ………….. 1
Add A + B + C = GCS