Ministry of Health, Labor and Social Protection of the Republic of Moldova [617798]
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Ministry of Health, Labor and Social Protection of the Republic of Moldova
Nicolae Testemitanu State University of Medicine and Pharmacy
STOMATOLOGY
Catedr a de chirurgie oro -maxilo -facială ș i implantologi e
orală"Arsenie Gu țan"
Licentiate thesis
Outpatient care in fractures of the facial skeleton
Shihada K lodia
Year 5, Group S1511
Scientific advisor :
Gulpe Alexei Serghei
Assistant Professor
Chișinău, 2020
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DECLARATION
I, Shihada Klodia , hereby declare on my own responsibility that the licentiate thesis entitled"
Outpatient care in fractures of the facial skeleton " is prepared by myself, the materials
presented are the results of my own research, are not plagiarized from other scientific papers and
have not been presented at another faculty or higher education institution in the country or
abroad. I also declare th at all sources used, including the Internet, are indicated in the licentiate
thesis, in compliance with the plagiarism avoidance rules :
✓ all fragments of text reproduced exactly, even in my own translation from another language,
are written with referenc e to the original source ;
✓ rewriting of the texts of other authors in my own words has the reference to the original
source ;
✓ summary of other authors' ideas has the exact reference to the original text ;
✓ work methods and techniques taken from other sources have exact references to original
sources .
Date 12.04.2020
Graduate Shihada Klodia ___________________
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CONTENTS
INTRODUCTION ………………………….. ………………………….. ………………………….. ……………….. 5
Actuality of the problem ………………………….. ………………………….. ………………………….. ……. 5
Aim of the thesis: ………………………….. ………………………….. ………………………….. ………………. 5
I. The bibliographic analysis of the theme ………………………….. ………………………….. …………… 7
1.2 Diagnostic information sought in the history ………………………….. ………………………….. ….. 7
1.3 Examination ………………………….. ………………………….. ………………………….. …………………. 7
1.3.1 SPECIAL INVESTIGATIONS ………………………….. ………………………….. ……………….. 11
1.4 SURGICAL INTERVENTION IN THE MANAGEMENT OF MAXILLOFACIAL
INJURY ………………………….. ………………………….. ………………………….. ………………………….. 12
1.4.1 Surgery for fractures of the zygomatic complex ………………………….. ………………………. 12
1.4.2 Operative procedures for Le Fort pattern fractures ………………………….. …………………… 14
1.4.4 The nature of fixation ………………………….. ………………………….. ………………………….. … 16
1.5 Infection and maxillofacial fractures ………………………….. ………………………….. ……………. 16
1.6 Repair of facial lacerations ………………………….. ………………………….. ………………………… 17
1.7 Tips for soft -tissue repair ………………………….. ………………………….. ………………………….. . 17
1.8 Psychological injury ………………………….. ………………………….. ………………………….. …….. 18
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1.8.1 Dental injuries ………………………….. ………………………….. ………………………….. ………….. 18
1.9 REHABILITATION ………………………….. ………………………….. ………………………….. …….. 19
1.9.1 MEDICOLEGAL MANAGEMENT ………………………….. ………………………….. ………… 19
2.Long -term complications after facial trauma ………………………….. ………………………….. ….. 20
2.1 Wound healing and prevention of scar formation ………………………….. ……………………….. 20
2.1.1. Initial management of wounds ………………………….. ………………………….. ……………….. 20
2.1.2 Scar classification ………………………….. ………………………….. ………………………….. ……… 20
2.2.2 Prevention of scar formation ………………………….. ………………………….. …………………….. 21
2.3 Nasal fractures: aesthetic deformity and nasal obstruction ………………………….. …………… 22
2.3.1 Septal perforation after trauma ………………………….. ………………………….. …………………. 22
.2.3.2 Saddle nose deformity ………………………….. ………………………….. ………………………….. . 23
2.3.3 Sinus problems ………………………….. ………………………….. ………………………….. …………. 24
2.3.4 .Nasolacrimal duct obstruction ………………………….. ………………………….. …………………. 26
2.4 Post -traumatic cerebrospinal fluid (CSF) leak ………………………….. ………………………….. . 27
2.5 Long -term complications in trauma of the ear and temporal bone fractures ……………….. 28
2.6 Swallowing and speech ………………………….. ………………………….. ………………………….. …. 28
2.7 Rare complication: pseudoaneurysm ………………………….. ………………………….. ……………. 29
3. Post -Operative Instructions: After Jaw Fracture Surgery Fracture ………………………….. ……… 30
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3.1 What You Need For Home ………………………….. ………………………….. ………………………… 30
3.1.1 Medications/Prescriptions ………………………….. ………………………….. ……………………….. 30
3.2 Care of The Operative Area ………………………….. ………………………….. ……………………….. 30
3.2.1 Swelling ………………………….. ………………………….. ………………………….. ………………….. 30
3.2.2 Bleeding ………………………….. ………………………….. ………………………….. ………………….. 31
3.2.3 Sore Throat ………………………….. ………………………….. ………………………….. ………………. 31
3.2.4 Lip Care ………………………….. ………………………….. ………………………….. ………………….. 31
3.2.5 Oral Hygiene/Mouth Care ………………………….. ………………………….. ……………………….. 31
3.3.3Muscle Spasm and Mobilization ………………………….. ………………………….. ……………….. 31
3.4 Diet ………………………….. ………………………….. ………………………….. ………………………….. . 32
3.5 Choking ………………………….. ………………………….. ………………………….. ……………………… 33
3.6 Nausea ………………………….. ………………………….. ………………………….. ……………………….. 33
3.7 Warning Signs of Complications ………………………….. ………………………….. ………………… 33
3.8 Physical Activity ………………………….. ………………………….. ………………………….. …………. 33
3.9 Follow -Up With Your Doctor ………………………….. ………………………….. …………………….. 34
Conclusion ………………………….. ………………………….. ………………………….. ………………………….. 37
BIBLIOGRAPHY ………………………….. ………………………….. ………………………….. ………………… 38
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INTRODUCTION
Actuality of the problem
In patients admitted to trauma wards, the focus is primarily on the initial management of
injuries. Cranial and facial trauma often result from high-energy mechanisms, the most frequent
being motor vehicle accidents (MVA), assaults or sports injuries. For this reason, patients can
present with multiple associated injuries. In life -threatening situations, the first priority is to
stabilize the pati ent. Once that is achieved, an evalu ation of the situation will be made and a more
conservative or surgical approach chosen. In making this decision, many factors must be taken
into account, though recently there has been a growing tendency towards more in vasive treatment
approaches. Complications in the long -term are always a possibility and depend on the localization
of the initial injury, but can also arise from the treatment itself.
Complications that arise after treatment of fractures can result in si gnificant morbidity.
Identifying modifiable risk factors associated with these complications is valuable in guiding
clinical practice for improved patient outcomes.
Complications after facial fracture treatment include quality -of-life issues such as numbne ss,
malocclusion, pain with mastication, and poor wound healing. After surgical intervention, local
wound complications can include wound dehiscence, surgical site infection, hardware extrusion
or exposure, and bony malunion or nonunion. Prior studies have associated increased rates of
complication with patient factors, such as smoking and delay in receiving medical care. The role
of other factors, such as fracture characteristics (location, comminution, and number), antibiotic
use and type, comorbid illnes s, and early surgical intervention, are controversial, particularly in
studies in which lack of multivariate analysis creates difficulties in identifying independent and
nonconfounded risk factors for complication. Furthermore, the wide variety in patient
presentation, practice patterns, and poor follow -up and/or compliance have contributed additional
challenges to studying the outcomes of facial fracture management.
Aim of the thesis:
The purpose of this thesis is to determine which factors are associated with an increased risk of
post treatment complication in patients with facial fractures .
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Our secondary aim is to determine the rate and type of intervention used to manage patients
presenting with a complication from repair of a facial fractures .
Objectives :
1. Improve the awareness of patients on the importance of following doctors recommend s and
it's reflection in their life.
2. Improve the motivation of patients to keep on check ups and c ommitted to the post operative
instruction s.
Theoretical importance and applicative value of the work
nt a of developme possibility the , treatments , types, In this thesis, studied about facial fractures
post operative complication, post operative instructions methods of controlling this complication
, the importance of check ups .
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. The bibliographic analysis of the theme I
1.1 Background
Facial fractures occur for a variety of reasons related to sports participation, or contact with
the environment, obstacles, and the most commonly associated soft tissue injuries were found in
the head and neck region.
1.2 Diagnostic information sought in the history
● Alteration in the way the teeth meet
● Pain site(s), aggravating, relieving factors, severity
● Numbness of skin, mucosa and teeth
● Alteration in ability to speak, swallow, chew, open mouth
● Disturbances of vision: blurring, double vision
● Reduced patency of oral and nasal airway
● Hearing disturbance
● Abnormal sounds from the jaw joints
● Neck problems .
.3 Examination 1
Very often, by the time a dental practitioner is called to see an injured person, some radiographs
have already been obtained. Looking at these before seeing the patient is a mistake. An enormous
amount can be missed from focusing first on radiographs. For example, they do not show soft –
tissue injuries and superimposition often makes primary diagnosis of mandibular, symphyseal and
cranial base fractures difficult or impossible. Much information can be gained simply by
observation of the patient. Although de ntal practitioners will usually not be responsible for
managing injuries outside the maxillofacial region, examination should always start with an
overall assessment of injuries.Pay particular attention to signs of bleeding or other discharge from
the ears , eyes, nose and mouth. In seriously injured patients there may be leakage of cerebrospinal
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fluid from the ears or nose. Look for signs of impact, including on the scalp. Abrasions or
haematomas often signal the sites of underlying bone injury. There is of ten little swelling in the
immediate aftermath of injury. However, within 6 hours mandibular angle fractures, for example,
are often associated with swelling over the angle and subcondylar fractures with preauricular
swelling. Always take a systematic appr oach to the examination of the maxillofacial region. As
with occipitomental radiographs, start superiorly and work down the face in a series of arcs to
reduce the c hances of an injury being miss
An examination may follow this order :
● start by considering the scalp
● then the frontal bones and supraorbital ridges
● then the orbits and nasoethmoidal region (traumatic telecanthus and a saddle nose deformity)
● then the external auditory meati, zygomatic arches and infraorbital margins
● then the zygomatic buttresses, alar regions and upper teeth
● finally the temporomandibular joints, mandible and lower teeth .
Having carried out a thorough inspection of the mouth and face, the facial skeleton should be
palpated in the same systematic manner, paying particular regard to :
● asymmetry —to help identify bruising, oedema or fractures
● step defects —to help identify bone fractures
● discontinuity —to help identif y bone fractures
● crepitus —to help identify the presence of air in the tissues
● tenderness
● neurological deficit —cranial nerves V and VII; also III, IV, VI if there are signs of orbital
injury —to identify nerve injury
● missing and mobile teeth
● mobility of the mid -face—to help identify a mid -face fracture. Stand behind and above the
patient when assessing facial asymmetry, particularly in relation to suspected zygomatic fractures.
In this position place an index finger on the maximum convexity of the zygoma on both sides
equidistant from the tip of the nose. Then compare the overlap of the index fingers with the
supraorbital ridges. Mobility of the middle third of the face, such as that brought about by Le Fort
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I, Le Fort II and Le Fort III patt ern fractures is best assessed by placing the patient’s head securely
against a head rest, grasping the upper teeth and alveolus and moving them gently, but
purposefully, laterally, superiorly and anteriorly. Simultaneous palpation of the nasal bones has
often been advocated but this can give rise to false -positive findings because of the mobility of the
scalp and skin in this region. A ‘cracked cup’ sound when the upper teeth are percussed can be
diagnostic of a Le Fort pattern fracture .
Le Fort pattern fractures :
● Le Fort I: Horizontal fracture of the maxilla immediately above the teeth and palate
● Le Fort II: Pyramidal fracture extending from the zygomatic butt resses through the
infraorbital margins to the bridge of the nose
● Le Fort III: Detachment of the facial bones, including the zygomas, from the skull base
A good test for a mandibular fracture is to exert gentle but purposeful backward pressure on the
symphysis. The patient will indicate discomfort at the angles or condyles if there are fractures in
these regions. If there is symphyseal injury or injury of t he overlying skin, then gentle medial
pressure on both mandibular angles simultaneously may provide evidence of mandibular fracture
in or near the mandibular midline. Although a comprehensive examination of cranial nerve
function is not usually necessary, hearing loss may be investigated by rubbing the thumb and
forefinger together 1 –2 cm from the patient’s external auditory meatus. Hearing loss may be
caused by blood in the external auditory meatus or, exceptionally, may be associated with a cranial
base f racture or neurological dysfunction. Whatever the cause, hearing deficit should prompt
referral to an otolaryngologist. Examination of the orbits and eyes should focus first on visual
acuity, diplopia in the various directions of gaze and evidence of bleed ing into the surrounding
skin, under the conjunctiva, or into either chamber of the eye. Anterior or poste rior displacement
of the globe gives rise to exo phthalmos and enophthalmos respectively and is most important in
relation to the diagnosis of retro bulbar haemorrhage (because this condition can give rise to
irreversible blindness if left untreated), or a ‘blowout’ fracture of the orbital fl oor or medial wall.
Examination of the canthi is important for eliminating the possibility of traumatic telecan thus
(widening of the distance between the inner canthi due to detachment from sound bone). Corneal
abrasions, conjunctival tears and eyelid laceration or loss need to be sought by careful examination
of the eyes and charted thoroughly. Diplopia (double vi sion) is most often caused by haemorrhage
or oedema in or adjacent to extraocular muscles, but can be caused by mechanical tethering of
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muscle attachments or by injuries to the third, fourth or sixth cranial nerves. Thorough examination
of the nose is an a spect of maxillofacial examination often neglected and includes attention to :
● symmetry
● deformity in all three dimensions
● bilateral or unilateral epistaxis (bleeding from the nose)
● possible leak of cerebrospinal fl uid (identity may be confir med by high sugar and low protein
content )
● septal haematoma or disruption
● anosmia or paranosmia (absent or altered sense of smell)
● crepitus (grating sound) associated with mobile nasal bones
● unilateral epistaxis, often associated with an ipsila teral (same sided) fracture of the zygoma,
secondary to bleeding into the maxillary antrum .
Examination of the mouth with a good light, paying attention to the junction of the hard and soft
palate (Le Fort pattern fractures cause haematomas here), dental a rches and the sulci, is important.
The teeth should be charted, noting particularly broken teeth and retained roots, especially those
that are very mobile and which may cause airway embarrassment. Gentle but purposeful pressure
should be applied to all tee th to detect possible dentoalveolar fractures, a split palate and fractured
teeth. Patients with fractures of the mandible between the mental foramen and the mandibular
foramen often have reduced levels of sensation in the distribution of the inferior alve olar or lingual
nerves and patients with zygomatic fractures often have areas of reduced sensation in the
distribution of the infraorbital and anterior superior alveolar nerves. Any such areas of altered
sensation should be recorded. Intraoral soft -tissue injuries are usually obvious and some extensive
lacerations of the hard and soft palate may be present —for example, if a child has impacted a toy
or other object into the mouth during a fall. Sublingual haematomas and tears at the gingival
margin can be di agnostic of mandibular fractures. Examination of jaw function should include
meas -urement in millimetres of maximal comfortable mouth opening from the tips of the central
incisors on one side; this should be recorded clearly in the medical records. Abnorma lities of jaw
function should be sought and recorded: these include deviation on opening, abnormal joint sounds
and disrupted occlusion. Temporomandibular joint dislocation is rarely a result of injury but
traumatic effusions can give rise to temporary mil d posterior open bite. Crucially, anterior open
bite can be a feature of Le Fort pattern fractures in which the middle third of the facial skeleton
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moves backwards and downwards on the cranial base or of bilateral fractures of the mandibular
condyles in wh ich the pterygomasseteric sling shortens the ascending rami. It is important to carry
out a thorough examination of the skin of the face, including the pinnae, the scalp and the neck.
Areas of numbness or partial numbness should be assessed by means of tou ch testing, compari ng
sides and two-point discrimination and recorded. Careful attention needs to be paid to all facial
orifices, in particular to discontinuity of eyelids, external nares, the external auditory meati and
the vermilion border of the lips. H igh-quality soft -tissue reconstruction depends on accurate
repositioning of the oral mucosa, musculature and skin in these areas .
.3.1 SPECIAL INVESTIGATIONS 1
Special investigations should only follow thorough clinical examination: many fractures have been
missed by ordering radiographs first. Radiographic examination forms the basis of special
investigations of maxillofacial injury and should be specific to the areas of concern. Radiographs
should be obtained according to the following categorization :
● skull views: posteroanterior and lateral
● mid-face: two occipitomental views at different angles
● nasal bones: soft tissue lateral
● tooth -bearing areas of the jaws: orthopantomogram and posteroanterior
● nasoethmoidal region and orbits: coronal computed tomography
● teeth: periapical and occlusal .
Radiographs may be necessary not only to reach a d iagnosis but also to inform treatment decisions,
for example, about where bone plates should be applied. They also commonly reveal injuries
which may not need treatment, for example, undisplaced or minimally displaced fractures, medial
blow -out fractures o f the orbit and comminution of the midface.R adiographs provide much more
detailed information on hard -tissue injuri es than the clinical examination so they may, for example,
show fractures of the roots of teeth and signs of associated soft -tissue abnormali ty, such as
herniation of orbital con tents into the maxillary antrum .
Additional tests may include hearing tests (though these are almost always performed by
audiologists or otologists), tes ts for monocular and binocular single vision such as Hess testing (by
orthoptists) and various other ophthalmological tests. The management of patients with multiple
maxillofacial injuries relies on teamwork, and it is preferable for specialist ear, eye an d
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neurosurgical tests to be ordered by the relevant specialists so that treatment can be comprehensive
and coordinated .
1.4 SURGICAL INTERVENTION IN THE MANAGEMENT OF
MAXILLOFACIAL INJURY
Many facial injuries require no active treatment and heal spontaneously. Examples include small
haematomas, clean abrasions, small lacerations, undisplaced stable fractures and some displaced
fractures, such as those of the mandibular condyle where the occlusion is not deranged or where
the occlusion settles spontaneously. As with any surgical intervention, a crucial decision is whether
operative treatment will benefit the patient. Given there are few randomized controlled trials, and
given the recorded clinical experience of generations of oral and maxillofacial surgeons, the
management of maxillofacial trauma is more of an art than a science. It is possible to overtreat or
undertreat. For exam ple, one may overtreat mandibular condyle fractures if it is not appreciated
that many displaced fractures of the neck of the condyle heal spontaneously without complications.
Similarly, neglect of grossly displaced condylar fractures can give rise to long -term occlusal
derangement. Indications for surgery and brief descriptions of appropriate operative procedures
are set out below. As in orthopaedics, the principles of treatment are :
● reduction —repositioning fr agments of b one to their anatomical positions
● fixation —making sure fragments remain in position until fractures have healed
● immobilization —preventing the broken bone from moving during the healing period
● rehabilitation —returning the patient to nor mal function after the fracture has healed
Although these principles remain the cornerstone of management of fractures, immobilization is
now much less important than it has been historically. This is because research has demonstrated
that complications su ch as long -term jaw stif fness, airway restrictions and psychological problems
are greater if the jaws are immobilized (traditionally by wiring them together). Furthermore, the
advent of small bone plates provides a method of fixing many fractures precisely and with a degree
of stability which makes immobilization unnecessary
1.4.1 Surgery for fractures of the zygomatic complex
Indications for surgical intervention include :
● flattening of the zygomatic prominence or externally obvious zygomatic arch depression
tethering of the eye secondary to orbital fl oor fracture
● mechanical interference of the coronoid process by the overlying zygomatic body
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Trismus often resolves spontan eously because it is often not caused by mechanical interference
but by haemorrhage into the masseter or temporalis muscles. The basis of treatment for zygomatic
fractures remains the Gillies’ procedure. This depends upon the anatomical
relationship of the temporalis fascia, which is attached to the superior aspect of the zygomatic
arch, and the temporalis muscle, which passes beneath the zygomatic arch and body and is attached
to the coronoid process and anterior asp ect of the ascending ramus. Thus, if an elevator is passed
between temporalis fascia and muscle, it can be used to elevate the displaced bone from
underneath. Access is achieved by making a 2 -cm incision in the temporal scalp, above and in
front of the ear and incising through temporalis fascia. If the elevated bone is unstable then it is
necessary to stabilize the zygoma with mini -plates across the fracture lines in the zygomatic
buttress region, the zygomaticofrontal suture (particularly if the frontal pr ocess of the zygoma is
displaced medial to the zygomatic process of the frontal bone) and the zygomaticomaxillary
region. Surgic al approaches to the orbital fl oor are necessary to retrieve orbital contents from the
maxillary antrum and prevent recurrence b y the insertion of a graft of either bone or synthetic
material. Transconjunctival (with or without lateral canthotomy) and transcutaneous (lower lid or
infraorbital) approaches to the orbital fl oor are in use. The principal objective is limitation of
scarring in this most visible and socially important area of the face while gaining sufficient access
to the fracture site. Minimizing skin scarring has to be balanced against risks of corneal and
subconjunctival injury. Isolated fractures of the zygomatic ar ch are much less common than
fractures of the zygomatic complex (separation of the entire zygoma) but operative intervention is
sometimes necessary because untreated fractures give rise to cosmetic problems or arch/ coronoid
interference, resulting in rest riction of mandibular movement. Again the Gillies’ approach is the
basis of treatment. As the zygomatic arch is not a substantial bone, reductions are sometimes
unstable and splinting is occasionally necessary. There are a number of ways of doing this —for
example, using a Foley catheter infl ated under the arch for 48 hours, or using external splinting
by means of transcutaneous circumzygomatic sutures. In extensive or panfacial (multiple fractures
of all or most regions of the facial skeleton) trauma, it m ay be necessary to gain access to
craniofacial sutures at a number of sites; in these cases, the coronal scalp fl ap can be invaluable.
In this approach, a coronal scalp incision is made above the hairline, allowing the scalp to be turned
down over the fac e to expose the nasoethmoidal and zygomatic regions. Thus, for example, by
such an approach it is possible to reduce a complex nasoethmoidal fracture, repair a cerebrospinal
fl uid leak and reduce and fix bilateral zygomatic or Le Fort pattern fractures. T he basis of the
surgical treatment of nasoethmoidal fractures is reduction of the canthal attachment and reduction
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of the nasal bones. Very often, the medial canthal ligaments are not simply detached from the
bone, but rather the ethmoid bone to which they are attached fractures from the rest of the
nasoethmoidal skeleton. The basis of treatment is usually the reduction of intercanthal distance to
normal by approximating the medial canthal ligaments using a wire suture .
The basis of treatment of fractures of the nasal bones is reduction of each nasal bone and the nasal
septum using instruments inserted into the anterior nares. Nasal splinting is often inadequate,
particularly with T -plasters, which simply compress haematoma and oedema rather than stabilize
the reduced nasal fracture. It is therefore often necessary to provide intranasal splinting using, for
example, expansive fl exible splints or tulle gras (paraffin wax impregnated gauze) to prevent the
nasal bones from fal ling medially. Occasionally, nasal trauma gives rise to bilateral septal
haematoma, which should be drained early to avoid necrosis of the cartilaginous septum .
1.4.2 Operative procedures for Le Fort pattern fractures
These fractures are sometimes undisplaced or minimally displaced, resulting in minimal occlusal
derangement, which corrects itself with masticatory function during the first week. Indications for
operative intervention are asymmetry, displacement, comminut ion and sustained occlusal
derangement. As with almost all fractures of the mid -face, immedia te surgical intervention is
rarely necessary. Exceptions include haemorrhage and the need to take the patient to the operating
theatre for surgery for other injuri es. There are many advantages in leaving definitive treatment
until 5 –7 days have elapsed. These include resolution of soft -tissue swelli ng that makes operative
assessment and access difficult, resolution of any brain injury or other systemic trauma and
resolution of any acute intoxication with alcohol or other drugs. The basis of treatment for these
fractures is direct visualization of the fracture sites and fixation with mini -plates, payin g particular
attention to achieving the correct occlusion. Postoper ative intermaxillary fixation (IMF) is rarely
necessary, although retention of arch bars (metal bars wired to the teeth facilitating wiring the jaws
together) may assist if there are mandibular fractures that have not been fixed directly and for
which elas tic traction (pulling the teeth into the correct position using elastic bands) may be
necessary to settle the occlusion .
1.4.3 Operative procedures in the treatment of fractures of the mandible
Most fractures of the teeth -bearing part of the mandible require operative intervention to restore
occlusion and minimize pain due to mobility. Undisplaced fractures, especially in children, may,
however, not requ ire operative intervention. Open reduction and fixation with mini -plates is the
treatment of choice for displaced fractures of the teethbearing aspect of the mandible. Mini -plates
15
are usually applied intraorally to the exte rnal oblique ridge in the case of angle fractures or to the
midline in the case of symphyseal fractures. The placement of plates is critical in relation to :
● avoiding close proximity to the oral mucosa
● use of two parallel plates where the use of only one may lead to a fulcr um about which the
healing mandible may become mobile
● the anatomy and distribution of the roots of the teeth
● the course of the inferior dental nerve
● comminution, where non -linear and multihole plates may be necessary
As with the use of implants at other sites, for example in hip replacement, biocompatibility is not
as important as it is in dental implantology. Thus, success has been achieved in terms of
biointegration with stainless steel, cobalt -chrome alloy and titanium mini -plates and screws, th e
costs of which are generally great. There are numerous types of mini -plates curren tly on the world
market and there are clear opportunities for cost savings if a generic rather than a proprietary
approach is adopted, as with drugs. Disadvantages of the u se of plates include the need for access
to the fracture sites and potential for infection and plate mobility leading to plate loss. Teeth in
fracture lines should normally be retained to assist in the accurate reduction of both fractures and
the occlusion . They act as spacers and their loss can lead to poor reduction. However, if teeth are
fractured, displaced from the socket or terminally diseased in relation to periodontal disease or
caries they should be removed. Fractures of the ascending ramus and con dyle of the mandible are
almost always of the condylar neck. The most important distinction to be made is between condylar
fractures that involve the articular surface and those which do not .
Because th e occlusion and masticatory function tend to maintain the dimensions of the ascending
ramus, operative intervention is normally necessary only when the occlusion does not return to
normal within the first 10 days after trauma. All intracapsular fractures s hould be mobilized
immediately and solitary intracapsular fractures are unlikely to affect the occlusion unless there is
a traumatic effusion. The majority of subcondylar fractures heal with no long -term occlusal
disturbance: the support provided by the oc clusion is akin to the weight of the arm, which is
normally sufficient to maintain a fractured humerus in a satisfactory position without recourse to
surgical intervention. Condylar fractures that may benefit from open reduction and internal
fixation are t hose where :
● there is gross displacement with wide separation of the bone ends
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● there is little or no sign of the occlusion settling by 10 days
● bilateral fractures are causing anterior open bite
● it is necessary to reconstruct the condyle to establish the integrity of the mandible before
fixation of central mid -face fractures
● there is a fracture dislocation .
Fractures of the co ndyle may be reduced and fixed using mini -plates or tra nsfixion screws and
the approach may be intraoral or extraoral. Precision at operation is critical because errors may
be magnified in the tooth -bearing part of the mandible .
1.4.4 The nature of fixation
Most mini -plates provide slight fl exibility and are therefore forgiving of minor errors in fixation.
Slight movement at the fracture area during the healing period is an advantage because it promotes
osteogenesis through the ‘fixator’ effect, firs t described in orthopaedics, which accelerates healing
through periods of slight, controlled, movement of a fracture. Rigid fixation with substantial
‘reconstruction’ plates requires very precise surgical techniques but is more often successful in the
presence of infection. Wire fi xation has too much in -built fl exibility, leading to deformation in
function. Traditional means of immobilizing the jaw with intermaxillary fixation are eyelet wires
and arch bars. Both provide wire loops, through or around which tiewires are passed. Arch bars,
intraosseous screws or orthodontic brackets may be used if elastic traction is necessary, for
example, to maintain the occlusion after bilateral subcondylar fractures. With mini -plates,
intermaxillary fixation is usually not required, apart from intraoperatively to maintain occlusion
while mini -plates are applied .
1.5 Infection and maxillofacial fractures
Although most maxillofacial fractures are compound into (communicate with) the mouth or
paranasal sinuses, the incidence of infection is low in otherwise healthy patients. Bone surgery and
grafting increase the chances of infection but this risk can be reduced by giving broad -spectrum
antibiotics during the operation, using the intramuscular or intravenous routes and postoperatively
using the oral route. Stabilization of middle -third fractur es with antral packs is associated with
more infection than other means of stabil ization. Small fragments of bone, particularly in the mid –
face, rarely become infected. Gross infections of non -united mandib ular fractures usually require
sequestrectomy and rigid fixation with reconstruction plates .
17
1.6 Repair of facial lacerations
It is important not to neglect soft -tissue injuri es because of too sharp a focus on underlying
fractures .
These injuries usually comprise abrasions, contusions and lacerations but deep, penetrating
injuries and loss of soft tissue may also occur, particularly in firearm wounds. Many of the
principles of management have been set out above but, in summary, skin, oral mucosa and
intervening musculature should be repaired accurately in layers, especially at the margins of the
eyes, nose and lips. Account should be taken of the orientation of the muscles of facial expression.
Inaccurate repair of a laceration of the vermilion border can lead to an ugly step defect and the
need for scar revision. Even minor scars can be constant reminders of the original trauma as well
as socially embarrassing. Resorbable suture material should be used for the oral mucosa and
musculat ure and it is important that the oral mucosa is allowed to heal before muscle sutures
resorb. Continuous sutures are often useful for linear mucosal lacerations and can be useful
externally. Accurate repositioning of irregular wounds nearly always necessit ates the use of
interrupted sutures. Infection rates are lower with monofilament suture material (like nylon) than
with multifilament or braided suture material (like silk) .
1.7 Tips for sof t-tissue repair
● Look for and remove all foreign bodies: skin tattoos are preventable. Fragments of glass,
wood, road grit and gun projectiles can often be identified using radiographs. Copious irrigation
can be used to fl ush out multiple small fragments .
● When repairing lacerations of the eyelids or vermilion border tack the mucosa/ skin borders
accurately together before proceeding with muscle repair .
● Excise obvious cyanotic skin tags; otherwise they will become necroti c and cause a lumpy
scar.
● Apply a broad -spectrum anti biotic preparation to the skin after repairing lacerations; infection
of minor wounds is surprisingly common .
● Do not shave the eyebrow when suturing this area .
● Use magnification routinely when s uturing facial lacerations; this aids precision .
● Suturing all but the simplest facial lacerations takes time: children and some adults need
general anaesthesia/sedation to give time for a high standard of repair .
● Operate on fractures before soft -tissue injuries: traction of the lips during fixation of fractures
can ruin soft -tissue repairs .
18
1.8 Psychological injury
About one -third of adul ts with maxillofacial skeletal injury and lacerations more than 3 cm long
develop post -traumatic stress disord er (PTSD). This may be defined as acute or chronic, depending
on the basis of persistence after 6 months. A diagnosis of P TSD requires the presence of fl ashbacks
to the trauma that produced injury, depression, sleep disruption and irritability/hyperarousal
(‘jumpiness ’).
The risk of developing PTSD is increased for patients with a previous history of psychiatric illness,
patie nts who are upset immediately after their injury and people who have been injured in assaults.
It has been shown that house surgeons/residents can predict accurately, on the basis of how
shocked the patient appears to be initially, who will go on to develo p PTSD. The symptoms of
PTSD can be reduced by early intervention, for example cognitive -behavioural t herapy, for those
at risk, who should be referred early to relevant mental health professionals. Liaison psychiatrists
are becoming important members of t rauma teams. However, nontargeted, blanket mental health
interventions, such as ‘critical incident debriefing’, are now known to do more harm than good.
Psychological problems are not limited to PTSD and may include anxiety, fear of further injury or
depre ssion. The prevalence of these conditions is very high in people with facial injuries, and
dental practitioners need to be alert to them and have routes of referral to appropriate mental health
professionals and voluntary agencies such as Victim Support. I t is important not to separate the
physical effects of trauma from the psychological effects: the two are often interlinked and minor
physical symptoms such as lack of ordinary sensation in the lip can trigger the fl ashbacks of PTSD
1.8.1 Dental injuries
Thoroughly chart all dental injuries, including those of the enamel/dentine, root fractures and
displaced or avulsed teeth. Account for all the major fragments. Minor damage to the enamel
usually requires no immediate intervention. Exposed dentine should be dressed to control
sensitivity and prevent loss of vitality. Use thermal rather than electrical pulp testers: pulp reactions
can be misleading in the acute phase. Monitor pulp vitality closely but remember tha t non –
responding teeth may refl ect neurologica l rather than pulpal injury. Fractures of the coronal third
of the root of a single -rooted tooth usually necessitate extraction. Undisplaced fractures of the
middle and apical third of the root may repair without recourse to treatment. Wire loops can be
used to temporarily stabilize mobile teeth or a fracture between two teeth. Reimplanted teeth
require calcium hydroxide rootfilling at 1 –2 weeks to prevent later resorption. Avoid splints that
involve the gingival margins .
19
.9 REHABILITATION 1
Return to normal function and appearance is the goal of all clinical management. In many cases,
particularly of pan -facial trauma , definitive repair of soft -tissue injuri es and fractures is only the
first step in rehabilitation. Since mini -plates and direc t fixation have largely replaced
intermaxillary and internal wire fixation, there is great opportunity for early mobilization of the
mandible. This reduces the risk of permanent limitation of jaw movement. Many patients with jaw
fractures require restorati ve dentistry as part of their rehabilitation from either family dentists or
specialists in restorative dentistry. Lacerations sho uld be reviewed for at least 12 months to asses s
the need for scar revision, which should not normally be done earlier because scars change in
shape, bulk and colour over that time. Rehabilitation may include the need for the services of an
ophthalmic optician to replace spectacles or contact lenses or provide them for the first time if
there are permanent effects on vision. Advi ce from a dietitian may help patients whose nutrition
has been compromised through associated injuries of the digestive tract and for those who have
postoperative intermaxillary fixation. In relation to psychosocial rehabilitation it is important to
be awa re of the level and quality of support at home and to involve the voluntary sector if support
is lacking .
In many par ts of the developed world victim support organizations exist to provide social support,
help with practical difficulties (such as those that may follow a robbery),support with police
investigations, appearances in cou rt as prosecution witnesses and help wi th completing
applications for criminal injuries compensation. Family dental practitioners are responsible for
ongoing restorative care, and therefore have opportunities to monitor a patient’s psychological
state and refer if there is evidence of depressio n or more serious psychiatric problems such as
PTSD. Alcohol misuse predisposes to maxillofacial trauma. In both hospital and primary care
settings, effective treatments are available. Patients with maxillofacial trauma should be screened
for alcohol probl ems with a standard test, such as AUDIT (Alcohol Use Disorders Identification
Test) and appropriate treatment instituted .
.9.1 MEDICOLEGAL MANAGEMENT 1
Practitioners who treat patients with facial injury are often asked to provide factual statements
about the injuries and treatment and may be called upon as expert or professional witnesses to
interpret the causes and effects of such injuries. A medical re port should be completed promptly
according to solicitors’ instructions but practitioners should ensure that confidential information
about a patient is disclosed only with their written consent. All practitioners who treat patients
with maxillofacial inju ries should be prepared to give written reports and oral evidence in court.
20
Remember that it is not usually the standard of treatment or the possibility of negligence which is
important to the courts, but the causes, nature and effects of injury
: term complications after facial trauma-ongL.2
.1 Wound healing and prevention of scar formation 2
2.1.1. Initial management of wounds
Facial laceration is the most common injury encountered in the emergency room. The most
frequently injured areas are the forehead, eyebrows, upper eyelids, chin and lips. retrospectively
studied complications in 3234 patients presenting in an emergency room with facial lacerations
between 2011 and 2013. Only 48% underwent a fo llow-up control. M ost of the follow -up was on
a short -term basis as the majority of patients were tourist, completely restored after a few days or
did not present for control visits. Most complications were diagnosed soon after trauma,
demonstrating that w ound control and prevention of infection is essential. Especially in cases of
laceration involving the oral cavity, careful management is required to avoid infections. In the
study infections only occurred in wounds involving oral mucosa. Infections with m ild discharge
should be treated with dressing, gargling or oral antibiotics, while those with severe discharge
should be treated with stitch removal at the time of infection detection, drainage, infection control
for between four and five days and, if necessary, delayed repair. Five patients underwent scar
revision due to hypertrophic scarring, but keloid was not encountered .
2.1.2 Scar classification
Hypertrophic scars (HTSs) are de fined as scars that are visible and elevated, that do not spread
into surrounding tissues and that often regress spontaneously with excessive deposition of
fibroblast -derived extracellular matrix proteins and especially collagen, over long periods and
by persist ent in flammation and fibrosis characterize these scars. HTSs do not extend beyond the
general geographic margins of the wound, tend to regress over time, are usually raised no more
than 4 mm above the skin and are red or pin k in colour, hard and pruritic. In contrast, keloids may
continue to evolve over time and do in filtrate the surrounding tissue. Keloids appear as firm,
mildly tender, bosselated tumours with shiny surfaces. Although benign, these keloids are
aesthetically malignant. There may b e focal areas of ulceration and the epithelium is thinned. The
initial lesions are erythematous and become brownish -red before paling with age. They can
sometimes show hyperpigmentation and telangiectasia. The lesions preferentially develop on the
ears, sh oulders and presternal skin and usually present above the level of the surrounding skin.
There are no hair follicles nor other glands within the keloid area. It is recognized that these
21
lesions occur more frequently in African -American and Asian patien ts than in Caucasians, but the
etiology of this pattern is uncertain.The majority of individuals who develop HTSs and keloids are
young, with ages ranging from 10 to 30 years old. This is for a number of reasons: young people
are more prone to trauma, thei r skin generally possesses more elastic fibres, resulting in greater
tension, and the rate of collagen synthesis is greater in younger individuals. The elderly rarely
develop these lesions .
Prevention of scar formation2.2.2
Only two treatments have shown sufficient evidence for success in scar management: topical
application of silicone gel sheeting or ointment and the intralesional injection of corticosteroids. It
is important to inform the patient of the b enefits of frequent massage. Surgical adhesive strips
may provide some benefits for up to six weeks post -operation. Silicone sheeting has been
used sinc e the 1980s and i ts efficacy has been studied. It is used as both a preventive and a
therapeutic agent. Gel sheeting is effective for scar control, but patient compliance with the method
is not always satisfactory .The benefits of silicone gel may be explained by reference to several
of its functions. Firstly, it increases hydration of stratum corneum and thereby facilitates
regulation of fibroblast production and a reduction in collagen production. The use of silicone
gel results in softer and flatter scars. The scarred tissue is protected from bacterial invasion and
bacteria -induced excessive collagen production is prevented. Further, it modulates the
expression of growth factors and a balance of fibrogenesis and fibrolysis is restored.Si licone gel
reduces the itching and discomfort associated with scars. One of the advantages of silicone
gel in comparison to silicon sheeting is its easy administration, even for sensitive skin and in
children, and even in moving or irregular skin su rfaces, such as the face. For fresh scars, treatment
can be initiated from just a few days after wound closure until months after healing. In the study
below, some patients started treatment more than six months after injury. A tube of 15 g contains
scar twice a day for over 60 days. A study of 30 patients 2silicone gel to treat a 5 cm enough
showed a reduction in the grade of the scarring, with few side effects. An allergic reaction to the
silicone gel was seen in one case and mild desquamation was see n in two cases. Applying silicone
gel between two and three times a day (Dermatix , Scarban ) or wearing silicone gel sheets 12 –
24 h per day for between six and 12 months, with temporary interruptions when adverse effects
appear, is recommended . Intralesi onal injections of corticosteroids are also used as a therapeutic
agent in scar management. Steroid injections are painful and may lead to skin atrophy and
dyschromia. They are usually contraindicated for large scar areas and for children. Pressure
garmen ts are a standard method to accelerate the remodelling phase of wound healing in several
22
burn centres. Prophylactic pressure is recommended in burn patients requiring grafting or if
spontaneous closure of the wound takes longer than between 10 a nd 14 days .
.3 Nasal fractures: aesthetic deformity and nasal obstruction2
The nose is commonly injured in trauma because of its prominent position on the face. Many
nasal fractures can be managed without surgery by performing closed nasal reduction. Sometimes
revision surgery for more de finitive repair is indicated. If not treated within a week post –
trauma, a nasal fracture with bony deformity require s an osteotomy, septoplasty and sometimes
nasal vault repair. In high -energy trauma , such as motor vehicle trauma, with more complex
variants of fracture (e.g., naso -orbito -ethmoidal fra cture), immediate surgical correction may be
required. The most common complications after trauma, with or without surgical correction, are
cosmetic deformity and nasal obstruction. Repairing such complications is complex as it involves
all aspects of the nose: bone, cartilage and soft tissue. Any serious nasal trauma places patients at
risk for complications that may include nasal septal haematoma, septal perforation and possible
cerebral spinal fluid leak. Unrecognized or untreated septal haematoma can result in
cartilaginous septal necrosis with septal perforati on and/or saddle nose deformity. Damage to the
structural framework of the nose is often the cause of cosmetic deformity following nasal trauma,
while important complications can also arise if the nasal soft tissue is affected. The wound care
for scar mana gement in such cases is as discussed above. In case of large lacerations, it may be
necessary to perform skin grafting.An important consideration is the age of the patient. In children,
a more conservative treatment is often advocated in order to avoid dis turbing the development of
the nose. Long -term comparat ive studies between different treatment methods are not available.
An interesting study by Grymer however, studied 57 children treated by closed reduction during
childhood and compared their nasal function and aesthetics to those of a control group of 50
children without trauma. No difference was found regarding functional complaints, but deviations
of the external aspect as well as septum deviations and spine formations were more prevalent in
the fracture group
2.3.1 Septal perforation after trauma
A potential long -term complication after septal trauma is nasal septum perforation. Although septal
perforations are often discovered during routine consultations, they can result in symptoms like nasal
obstruction, nasal congestion, epistaxis, chronic purulent discharge or other nasal symptoms. The
presence of a septal p erforation can re sult in chronic rhinosinusitis. Treatment is based on surgery using
two main principles: repair using an intranasal flap (mucosal, mucoperichondrial or mucoperiosteal flaps)
and extranasal flaps. Sometimes obturation of the septal perforat ion is performed with a silicone button.
23
This technique was described in 1977, with the purpose of the button being not to heal the perforation but
merely to close the hole for as long as it remains in place. It successfully alleviates symptoms associated
with the per foration. Nasal septal perforation repair with temporal fascia and periosteal grafts was used in
98 patients in a study by Virkkula et al. Retrospective closure rates were followed and reached 78%. A
different method was presented by Emsen, who used an alar winged flap (AWF) in 13 patients with nasal
septal perforations with an average diameter of between 1.5 and 2.4 cm. There were no preoperative or
post-operative complications, and the AWF incision scar was cosmetically satisfactory. A wi de variety
of techniques and grafts have been introduced in the past, but res ults for large perforations are
poor. Discussion of all such techniques is beyond the scope of this article .
. 2.3.2 Saddle nose deformity
Septal haematoma and abscess formation can result in saddle nose deformity due to necrosis of
the septal cartilage. As a result of loss of septal support, functional and aesthetic impairment can
develop. Repair of septal support to improve airway function is an important consideration in
addition to aesthetic improvement. Cakmak developed an algorithm based on his experience
in septal support reconstruction in 206 patients with a mean follow -up of 32 months. Preoperative
examination, intraoperative assessment, reconstruction techniques, graft materials and patient
evaluation of aesthetic success were documented, and four different types of saddle nose
deformities were defined. Defining the different types helps to ide ntify the most appropriate
surgical procedure to restore the supportive nasal framework and aesthetic dorsum in each case.
Patient surveys revealed aesthetic improvement in 201 (98%) patients and improvement in nasal
breathing in 195 (95%) patients. Structural grafting is necessary and many such techniques are
available. The selection of graft material is important in the correction of saddle nose deformity,
but there is no consensus regarding the most suitable graft material. In general, autogenous g rafts
are considered to be safer than synthetic materials. Cartilage grafts are useful for the correction of
mild to moderate saddle nose deformity. Other possibilities are autogenous bone grafts, irradiated
rib cartilage grafts and synthetic materials.In 20 patients treated for this pro blem after trauma, Mao
found a good outcome (mean follow -up time of almost seven years) after using septal or conchal
cartilage grafts. Advantages are a readily available graft that achieves structural stability with
cosmeti c and functional satisfaction in most patients. Eren treated seven patients using
microplates and costal cartilage. The results were compared with those of the previously applied
costal cartilage repair methods (Kirschner wire and onlay costal cartilage) . The patients treated
with Kirschner wire inserted cartilages and those treated with onlay dorsal costal cartilages
encountered complications such as extrusion of the wire and warping, respectively. The seven
24
patients treated with microplates and d orsal onlay costal cartilage grafts did not experience any
infection, warping or extrusion complications. In 19 patients, a novel technique with Kirschner
wire-guided suturing for permanent fixation for nasal d orsal reconstruction was used. The nasal
obstruction symptom evaluation showed a statistically significant improvement post –
operatively. None of the patients experienced nasal dorsal collapse or graft malposition. Two
patients had nasal dorsal irregularity complaints owing to inadequate costal cartilage edge
bevelling. None of the patients had complications related to suture reaction, suture visibility or
suture extrusion. All of the patients stated that they were happy with the cosmetic outcome.Diced
cartilage grafts have been used over the pa st decade in the correction of saddle nose deformity.
Revision surgery may be required in cases of problems like graft absorption or displacement. In
seven patients requesting tertiary rhinoplasty, a diced cartilage island is attached to the nasal dorsal
skin and released distally until the island can be transposed to the tip area.16 This island is formed
as an advancement flap, moved caudally and sutured to the posterior of the dome area. After a
follow -up of, at minimum, one year, all patients were satisf ied with the result and no complications
were observed.One of the disadvantages of using carved or crushed cartilage as a graft is that
it may be perceptible through the nasal skin after tissu e resolution is complete. Erol1 suggested
the use of Surgi cel® -wrapped diced cartilage in order to avoid irregularity. This was used on 2365
patients with nasal deformity (165 patients with traumatic nasal deformity). Harvested cartilage
(septal, alar, conchal and sometimes costal in severe defects) is cut into p ieces of 0.5 -1 mm,
wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin) .
This is moulded into a cylindrical form and inserted under the dorsal nasal skin. After a follow -up
of between one and 10 years, some complications were described: in six patients (0.3%), early
post-operative swe lling was more than usual; in 16 patients (0.7%), overcorrection was persistent
owing to fibrosis; and in 11 patients (0.5%), resorption was more than expected .
.3.3 Sinus problems 2
In facial trauma, sinus fractures can occur, with the most frequently injured region being the
maxillary sinus. If necessary, primary fracture surgery is performed to address foreign bodies in
the sinus cavities and/or wall defects. However, sinusitis can be a late complication and therefore
diagnosis and treatment cannot be performed on first admission. An illustrative case discussed is
of a patient presenting in the emergency room of our hospital in 1994 after facial trauma with
fractures of the orbital, ethmoid and frontal sinuses. In the acute setting, the patient lost his right
eye. Over the years, the patient had multiple episodes of surgery with orbital reconstruction. Nine
years after the trauma, the patient presented at an ENT consultation with head aches due to
25
pansinusitis with frontal and maxillary mucoceles A full functional endoscopic sinus surgery
(FESS) was performed. Sinusitis can result from the fracture itself, but can also be a complication
after surgical repair in the acute setting. H owever, reliably segregating the sequelae of injury from
post-surgical complications was considered to be impossible in this case. Recently, there has been
a trend towards a more aggressive surgical approach for optimal restoration of appearance and
functi on. Although outcomes the patient presented at an ENT consultation with headaches due to
pansinusitis with frontal and maxillary mucoceles . A full functional endoscopic sinus surgery
(FESS) was performed. Sinusitis can result from the fracture itself, but can also be a complication
after surgical repair in the acute setting. However, reliably segregating the sequelae of injury from
post-surgical complications was considered to be impossible in this case. Recently, there has been
a trend towards a more aggressive surgical approach for optimal restoration of appearance and
function. Although outcomes have thus improved, it is likely that the severity of the initial trauma
and the extent of injury are the factors de termining the final result. In the case of frontal sinus
fractures, the best treatment modality is still controversial due to the possibility of late
complications. This is due to the fact that sequelae may take years to develop and involve
intracranial structures with severe consequences (frontal mucoceles, sinusitis). There is a lack of
research evaluating such long -term complications due to the fact that it is difficult to follow
patients for up to 20 years. The goals of treatment in cases of facial trauma are isolation of
intracran ial contents, correction of cerebrospinal fluid (CSF) leak, prevention of infections,
restoration of functional integrity and restoration of fr ontal contours and aesthetics. If surgery is
performed, either sinus function should be recovered or the sin us should be eliminated by
obliteration or cranialization. Injured or devitalized sinus mucosa tissue should be removed. In
cases of extensive mucosal lesions, damage to the frontonasal duct or previous recurrent sinusitis,
complete removal is warra nted. Mechanisms causing facial fractures may be predictive of the types
of injuries sustained. An interesting study performed by Greathouse calculated the rate of surgical
intervention based on mechanisms of injury in a retrospective study with a subset of 1508 patients
sustaining facial trauma after a fall, assault or MVA. Fractures most likely to undergo surgical
treatment were caused by MVA. Mandible fractures were the most common injury leading to
surgical intervention. Lower age, number of fractures and lower alcohol level were statistically
significant variables associated with operative management .In children, the inherent plasticity
of the growing craniofacial skeleton renders operative intervention unnecessary in many patients.
Additionally, there is a fear of growth disturbance related to operative intervention, causing
surgeons to be more cautious and less likely to operate in less severe cases in this population .
26
2.3.4 .Nasolacrimal duct obstruction
In the case of naso -orbito -ethmoidal trauma, post -traumatic dacryostenosis can emerge. A
retrospective analysis of 58 patients with such fractures showed dacryostenosis in 46.4%. In some
cases, temporary epiphora was encountered with spontaneous recovery. In the patients with
complaints of a more permanent nature, an association with delayed treatment of the fracture or
presence of bone loss in the lacrimal district was found. Six months after primary surgery, external
dacryocystorhinostomy (DCR) was performed in all patients wi th persistent complaints, and a
success ratio of 94% in lacrimal drainage was attained. However, patients did report the temporary
presence of external scars and s tenting material as a problem. In another study, patients were
evaluated at least four months after trauma and subdivided into two groups: those without previous
surgery and those who had previously undergone a surgical procedure. In another retrospective
evaluation of 19 patients, two groups of patients were compared. The first group, who had
undergone initial surgical repair of naso -orbito -ethmoidal fra ctures (10 patients), suffered from
nasolacrimal canal obstruction in 50% of cases (five cases). The second group had no initia l
trauma surgery, and in that group 88.8% of the patients (eight cases) had nasolacrimal canal
obstruction as seen via dacryocystography. In a retrospective, non -comparative c ase series, 14
patients with epiphora after naso -orbito -ethmoidal frac tures were studied. In these patients, an
external approach was also used with positive results. Only one patient experienced failure
due to cicatricial closure of the ostium. In general, authors advise the use of endoscopic DCR as a
less invasive procedure , but few results in the context of trauma surgery are known. No studies
report series comparing external DCR to endoscopic techniques in these patients .
Orbital blowout fractures and repair
Very recently, a meta -analysis was performed showing interesting results in the outcomes of
patients with orbital fractures. Orbital blowout fractures are common injuries with associated risk
of persistent visual impairment and enophthalmos. Two subgroups of patients (442 patients) with
isolated blowout fractures were studied, the first group with early surgical intervention within
14 days of the trauma, the second group with later surgic al intervention. Patients in the latter group
showed a significantly higher risk of persistent post -operative diplopia as compared to the former
group. No difference was found between the groups regarding post -operative enophthalmos. Early
treatment of fra cture is advised to avoid complications.In a large series of paediatric trauma
patients (150 patient) treated for orbital fractures, four indications for surgery were defined as
follows: rectus muscle entrapment, early enophthalmos, central -gaze dip lopia or extraocular
movement restriction after resolution of swelling and loss of orbital support, likely to produce
27
secondary changes in globe position and/or binocular stereo
vision .
2.4 Post-traumatic cerebrospinal fluid (CSF) leak
Fractures of the skull or facial bones may lead to the formation of CSF fistulas. While most CSF
leaks will cease without treatment within two to seven days after trauma, patients with persistent
CSF leaks may be at increased risk for meningitis. In the existing literature, the incidence of post –
traumatic meningitis ranges from 0.38 to 10%. The time of on set after trauma generally ranges
from five to 13 days, but meningitis can present even years later and trauma history should thus
always b e taken into consideration. In some cases, patients present with recurrent meningitis due
to an occult leak. Trauma i s a frequent cause of r ecurrent bacterial meningitis. Failure of
conservative treatment is an indication for surgical repair. In cases of CSF leaks following trauma,
absolute indications for surgery are: profuse leaks; pneumocephalus; delayed or intermitte nt leaks;
persistent post -traumatic leaks after four to six weeks of conservative treatment; false CSF
rhinorrhoea coming from the petrous bone via the eustachian tube; and recurrent meningitis.
Transnasal endoscopic techniques are well tolerated with g enerally good outcomes. Closure rates
of surgical intervention are highest among patients in whom a multilayer technique for leak closure
is used (with a combination of a primary graft or sealing material like fascia, muscle, mucosal
tissue or bone wax).A retrospe ctive study by Friedman studied 51 patients with post -traumatic
CSF leaks. They described eight patients (16%) with occult leaks presenting with recurrent
meningitis at an average of 6.5 years post -trauma. Eight patients (16%) had delayed leaks at an
average of 13 days post -trauma. The frequency of meningitis was 10% with antibiotic prophylaxis
and 21% without antibiotic prophylaxis among patients with a clinically evident CSF leak.
Therefore, they suggest prophylactic antibiotic treatment. Patient s with CSF leaks that persist for
longer than 24 hours are at risk for meningitis, and many will require surgical intervention.
Different surgical techniques were used with good outcomes, though sometimes additional surgery
for continued leakage was indica ted. In another study by Sonig the US Nationwide Inpatient
Sample was analysed for factors associated with the development of post -traumatic meningitis.
CSF rhinorrhoea and CSF otorrhoea, as well as major neurosurgical procedures, were independent
predict ors of the development of meningitis. They also found that the presence of a closed skull
base fracture was a predictor for the development of a CSF leak. In 50.3% of the patients with CSF
rhinorrhoea, and even 64.1% of the patients with CSF otorrhoea, no concomitant skull or facial
fracture was reported. No specific subtype of maxillofacial fracture predicted the development of
post-traumatic meningitis. The use of prophylactic antibiotic treatment in skull base fractures
28
and CSF fistula is controve rsial.26,28 There is a tendency towards decreasing incidence of
meningitis when antibiotics are used in patients presenting with CSF leakage .
2.5 Long-term complications in trauma of the ear and temporal bone
fracture s
Some complications are already present in the immediate post -trauma follow -up, such as
perforation of the eardrum, hearing loss or facial nerve paralyses. Formation of an othaematoma
can result in a loss of cartilage of the external ear, as in septal haema toma, and urgent treatment is
required to avoid evolution to a cauliflower ear. Reconstruction of the ear presents a
significant challenge, even in the hands of an experienced surgeon. No one particular technique
will work in all situat ions, therefore options should be considered after the tissue deficit has been
defined. Availability of local tissue and surgeon preference are the most important variables, while
in some severe cases an epithesis should be considered. Between 4% and 30% of head injuries
involve a fracture of the cranial base, including 18 -40% with temporal bone involvement. 30
Multiple lesions to the neural and vascular structures in and around the temporal bone may
contribute to a diminished outcome in terms of quality of l ife. Montava et al.30 reported a
prospective series of 39 patients (with 45 temporal bone fractures). All patients were treated in
the acute setting. Sixty -nine percent underwent long -term assessment with a mean time of 17
months after injury. Qualit y of life questionnaires showed a significant reduction in quality of
life three months after trauma. After 12 months there was an improvement, but this outcome was
still significantly worse than before the accident. Difficulties were reported i n mood,
relationships, social embarrassment and impact on work.In this regard, especially, long -term
follow -up is importa nt. For instance, in cases of facial nerve paralyses, spontaneous recovery can
occur up to one year after trauma. Cochleovestibular se quelae are disabling and after one year
patients can present with balance problems, hypoacusis or tinnitus, all of which may go unnoticed
in the acute setting when more life -threatening i njuries are treated. Treatment with vestibular
rehabilitation and/or corticosteroid therapy should be initiated as quickly as
possible .
2.6 Swallowing and speech
The maxillofacial region contains important bony and soft structures for vital
functions: speech, swallowing and respiration. Studies to evaluate functiona l
outcomes after reconstruction are primarily conducted in cancer patients, but trauma
can cause similar functional limitations. In patients with maxillofacial gunshot wounds due to
suicide attempts, the entry wound is usually in th e submental area and the exit wound in the
29
frontal or midfacial region. Loss of both bony and soft tissue results in impairment of swallowing,
speech and respiratory functions. There is a lack of information concerning the functional
outcomes comparin g more conservative to su rgical approaches. Zor performed a functional
evaluation of outcome one year after treatment completion. Twenty male subjects with gunshot
injuries were included and compared to 10 male volunteers. Evaluation of swallowing function
was performed with video fluoroscopy, dynamic -MRI, submental EMG, ultrasonography and
functional endoscopic evaluation of swallowing (FEES) . Only two of these 20 patients showed
aspiration. Additionally, speech variables significantly differed between the treatment and control
groups. The results recommend that attention be paid to anatomical integrity, correct occlusion,
tongue release procedures and alveolar deepening in initial treatment. Swallowing therapies, such
as tongue stretching and Valsalva m anoeuvring, should be initiated in the early post -operative
period. Prosthetic rehabilitation and osseointegrated implants are also advised.Furthermore,
long-term intubation with ventilation after trauma or formation of scar tissue following burns can
cause impairment of speech and swallow functions. No studies reporting long -term follow -up in
such cases are available .
2.7 Rare complicati on: pseudoaneurysm
Pseudoaneurysms can develop after trauma when there is a partial disruption in the wall of a
blood vessel. The three branches of the external carotid artery that are most vulnerable are the
superficial temporal, facial and maxillary arteries. The risk of rupture is much higher than that
of a true aneurysm, as there is less support from the vessel wall because the haematoma is either
contained by the vessel adventitia or the perivascular soft tissue. Rupture can cause haemorrhage,
while progressive enlargement can cause compression of adjacent nerves or release of embolic
thrombi. A CT scan with contrast can lead to a correct diagnosis , but this is difficult to perform.
If a pseudoaneurysm is suspected, angiography sh ould be carried out. In cases of haemorrhage
compression, haemostasis and blood transfusion are indicated. Patients who have undergone
maxillary -mandibular fi xation after trauma should be instructed in how to release the fixation to
clear potential clo ts. After stabilization of the bleeding, surgical treatment (open technique) or
endovascular embo lization should be performed. The latter technique is preferred because it is
more selective and less invasive than the surgical procedure.A case was described in which facial
trauma caused a pseudoaneurysm of the maxillary artery and was diagnosed 21 days after the
trauma due to heavy bleeding. Catheterization of the maxillary artery and embolization
resulted in adequate haemost asis.
30
3. Post-Operative Instructions: After Jaw Fracture Surgery Fracture
.1 What You Need For Home 3
Syringe*
*Saline (to make your own: dissolve 1 teaspoon of salt in an 8 -ounce glass of warm water)
*Child sized toothbrush/Waterpik
*Scissors/pocket knife (for cutting elastics if your jaws are held closed)
Vaseline or lip balm*
Blender or food processor
.1.1 Medications/Prescriptions 3
If necessary, a prescription for medications will be provided at the time of discharge. the
medication should be taken as prescribed until it is finished. The patient may be sent home with a
prescription for a liquid pain reliever, which can be administere d through a syringe as been shown,
or sipped from a spoon. If the pain reliever is in pill form, the patient can crush it and mix it with
10–20 ml of water or juice to be supped or administered through a syringe .
a prescription for a liquid antibiotic may be given to prevent infection. It is important to take this
medication as prescribed until it is finished. also a prescription for an antibiotic mouth rinse be
given. It is very important to keep your mouth clean .
An increase in swelling and pain after the first week could indicate an infection, which may require
treatment. if this happen ,shou ld contact the doctor .
.2 Care of The Operative Area 3
3.2.1 Swelling
For the first 48 hours after surgery, the patient will be given ice packs, which will help to minimize
swelling. Following this period, will need to use heat (hot, wet facecloth, hot water bottle, heating
pad, or microwaveable pack) to help reduce the remaining bruising and swelling. As it takes about
2 weeks for the majority of the swelling to disappear, continue to use heat for 30 –45 minutes, 4 –5
times a day for at least 1 –2 weeks after discharged from the hospital. A few minutes of gentle
massage while using the heat also helps .
31
.2.2 Bleeding 3
Prolonged bleeding, such as nosebleeds or bleeding from the incision sites following discharge
from the hospital, is not normal, and the patient should contact the doctor if this occurs .
3.2.3 Sore Throat
For the first couple of days following surgery, the patient may experience a sore throat and some
nasal decongestion. This is normal after anesthesia and should go away within a couple of days.
Drinking plenty of liquids usually helps with the throat tenderness .
3.2.4 Lip Care
The patient will be unable to keep his lips moist when his jaws are held together with elastics. In
addition, cracking of the corners of the mouth does sometimes occur following surgery. Apply
Vaseline or lip balm regularly to k eep these areas from becoming too dry or chapped .
.2.5 Oral Hygiene/Mouth Care 3
It is important to remember to clean the teeth and rinse the mouth routinely foll owing surgery.
Using a Waterpik after the first week is an excellent aid. A mild salt solution or a commercial
mouthwash (non -alcohol based) will assist the patient in keeping his mouth clean. It is important
to rinse the mouth with 20 –30 ml of saline frequently every 2 hours as well as after meals. Use a
child toothbrush to clean the outside of the teeth. can start brushing the front of the teeth as soon
as it is not too painful and progress to the back of the mouth when the swelling in the cheeks comes
down. The patient will, of course, not be able to brush the tongue side of his teeth with a brush.
The tongue side of the teeth can be brushed by moving the tongue across them while using a mouth
rinse. should avoid carbonated beverages, as they tend to decalcify the teeth .
Muscle Spasm and Mobilization3.3
Occasionally, several elastics will break away during the fixation (teeth together) period. As long
as the patient cannot open his mouth significantly, this is not a problem, and elastics will be
replaced at one of your post -operative visits. If a large number of elastics are lost, and the patient
can open his mouth. The patient should , contact his doctor so that new elastics can b e
placed .
32
.4 Diet 3
Since the jaws may be held together with elastics, require a balanced fluid diet (blenderized). I t
is essential that the body receives adequate fluids and nourishment in order to maintain nutritional
status and promote healing .
The patient will be limited to a strictly liquid diet until the jaw is no longer tightly held together.
During this period, the patient will become creative with his menu choices. It is especially
important to drink adequate amounts of fluids, 3 –4 liters per day. The patiennt can purchase liquid
nutritional supplements (such as Ensure or Boost) in a grocery store. may continue to use the
syringe for feeding, or when the patient are comfortable, can use a straw or drink from a glass. A
nutritious dietary intake is impo rtant to promote healing and decreasing the possibility of infection.
The patient can expect to about 5 –10% of the total body weight during the first 6 weeks following
the surgery. A rapid loss of weight during the first week is usually due to fluid
loss.
After the first 6 weeks, the patient can progress slowly to a normal diet. The first 4 weeks following
the removal of the tight elastics, the diet should involve soft foods (eggs, potatoes, fish, pasta, etc.) .
Here are some tips for creating a personal menu :
* the patient may eat anything that can be thinned into liquid form. Meals may be blenderized
until smooth. If food is still lumpy, use a strainer
*Cold whole milk can be used to thin puddings, yogurt, cereal, sandwiches, ice cream, and cakes .
*Warm whole milk can be used to thin cheese, eggs, toast, hot cereal, muffins, pasta, hot main
dishes, and casseroles .
Fruit juice can be used to thin fruit, yogurt, and ice cream . *
Weight loss is a common result of a liquid diet. If experiencing weight loss, should try snacking
between meals and adding whole milk cheese or skim milk powder to the meals to boost caloric
intake. Constipation may result from the low fiber content in liquid diets or may be a side effect
of some pain medications. To a void this, should try to include a lot of fruits and vegetables in the
diet, and add prune juice to the daily menu .
Alcohol and smoking can delay w ound healing and promote infection. Alcohol and smoking
should be avoided until the surgical sites are completely healed .
33
3.5 Choking
In the unlikely possibility that choking or breathing difficulties may occur, It's recommend t o
have scissors or a pocket knife at all times while the teeth are wired together. In the rare
event that you need to cut the elastics, proceed with cutting the elastics and then contac t
the doctor immediately. The nurses will instruction in the art of cutting the elastics in the event
of an emergency.
3.6 Nausea
Avoid alcohol or foods that may cause the stomach to become upset. Should you experience
nausea, the patient can use over -the-counter anti -nausea medication as directed on the bottle. If the
nausea persi sts , contact the doctor .
In most cases of vomiting, the elastics do not require removal. It is extremely rare to have to
remove the elastics as the stomach contents are of liquid nature and can escape through and around
the teeth. If emergency elastic removal (for vomiting or brea thing difficulties) is required, please
contact the doctor immediately. Remember that during the tight fixation period (with elastics), the
patient should carry scissors or a pocketknife with you wherever you go .
.7 Warning Signs of Complications 3
The following symptoms may be a sign of infection or other complications; therefore, the patient
should follow up immediately with his doctor if they occur .
Redness*
Increased swelling*
Increased or excessive pain*
Foul odor from the mouth*
Fever and/or chills*
*Bleeding inside the mouth (wires may need to be adjusted)
.8 Physical Activity 3
Physical activity should be kept to a minimum for at least 6 –8 weeks after surgery. It is very
important to realize that the patient just had a significant operation that requires a well -rested
34
recovery period. Excessive activity (running, exerc ising, swimming, heavy lifting, house cleaning,
contact sports, going up and down stairs quickly, etc.) can cause bleeding and/or dizziness. If the
patient had upper jaw fracture, should avoid bending over during this time period as it may cause
dizziness .
Excessive fatigue can also slow the healing process as well as increase the chance of infection by
reducing resistance. A gradual increase back to normal activity is the most sensible approach.
Contact or other sports in which direct physical contact or in jury are possible should be avoided
for 2 –3 months to minimize the risk of another fracture. If the patient have any specific activities
he wish to perform following his surgery, should discuss this with his doctor .
.9 Follow -Up With the Doctor 3
A follow -up appointment should be arranged with the doctor’s office prior to discharge.
35
RESULTS AND DISCCUSIONS
Clinical case nr.1
Patient data
-Name: H. O. N .
-Gender: male
-Age: 31 y.o.
-Address: Chisinau
Fig. 1
The patient was traumatized by human aggression, he attended medical help the same day.
When he was advised to visit the dental surgeon for a regular outpatient control , he neglected the
recommendations and addressed more than two weeks after the trauma. The results of the
negligence can be viewed on fig. 1. An extra -oral examination did not revealed any significant
changes in symmetry of the face, nor any remarkable discontinuities at the level of the lower jaw.
On the other hand, an intra -oral exam revealed bended and deformed arch -bars, missing
circumdental wires that should maintain stability for the arch -bar. An another issue was a very
poor oral hygiene which led to gingivitis, bad breath smell. Overall, the negligence by patients in
outpatient care with fractures of the facial skeleton will lead to serious problems that can affect
their quality of life.
36
Clinical case nr. 2
Patient data
-Name: F. A. N .
-Gender: male
-Age: 28 y.o .
-Address: Chisinau
Fig. 2
Figure 2 is an example of a responsabile patient. Pay attention on the arch -bars that are straight,
clean. The gums are healthy without any soft or hard residues on them
37
Conclusion
In traumatic events, the focus is primarily aimed at the stabilization and treatment of the patient
in the acute setting. Many patients are lost in follow -up and often the long -term outcome is not
reported. Where the outcome is reported, most data are retrospective. Due to the large number of
patient and treatment variables, it is difficult to compare the long -term outcomes of different
treatment methods. Although long -term post -trauma complications are inevitable, it is important
to be a ware of these complications in order to provide the best possible treatment. An overview
of complications is presented above. In any case, the initial treatment of trauma is essential in
determining optimal functional and aesthetic outcomes in the long run, and close collaboration
between different specialisms is necessary to achieve good patient management, control and
follow -up.
38
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