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Trauma Maksilofasial

Trauma Maksilofasial. Drg. Moh. Gazali Malik, Sp.BM,M.Kes (MARS). BAGIAN ILMU PENYAKIT THT-KL FK UNTAD/RSUD UNDATA. Introduction. Maxillofacial trauma isolated injuries or part of poly trauma. (chest, head, cervical spine, abdomen or the extremities

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Trauma Maksilofasial

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  1. Trauma Maksilofasial Drg. Moh. Gazali Malik, Sp.BM,M.Kes (MARS) BAGIAN ILMU PENYAKIT THT-KL FK UNTAD/RSUD UNDATA

  2. Introduction • Maxillofacial trauma isolated injuries or part of poly trauma. (chest, head, cervical spine, abdomen or the extremities • Function , psychological and cosmetic. • The frequency high , face is exposed and little protective covering. • Location • Mandible (61%) • Maxilla (46%) • Zygoma (27%) • Nasal (19.5%)

  3. The etiology of maxillofacial injuries • motor vehicle or motorcycle accident most frequent • Assault • Domestic Accidents • Gunshots • Sports injuries

  4. Etiology • 60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. • 20-50% concurrent brain injury. • 1-4% cervical spine injuries. • Blindness occurs in 0.5-3%

  5. Pathophysiology • High Impact: • Supraorbital rim – 200 G • Symphysis of the Mandible –100 G • Frontal – 100 G • Angle of the mandible – 70 G • Low Impact: • Zygoma – 50 G • Nasal bone – 30 G

  6. Facial Skeleton

  7. Facial Buttress System Vertical buttresses Horizontal buttresses

  8. The maxillofacial region is divided: • Upper face; fractures involve the frontal bone and sinus. • Midface: • Upper; maxillary Le Fort II and Le Fort III • Lower; Le Fort I fractures • Lower face; fractures are isolated to the mandible.

  9. The treatment three phases. • primary phase , survival of the patient by maintenance airway function, breathing andhaemodynamics • intermediate phase, supportive line such as antibiotics prophylaxis , treatment of infections, control of bleeding, tissue debridement. • reconstructive phase. reconstruction of the soft and hard tissues ,reduction and fixation of bone segments, reconstruction of the nasolacrimal system, release of scar tissue, and correction of sensory and motor nerve dysfunction

  10. Emergency ManagementAirway Control • Control airway: • Chin lift. • Jaw thrust. • Oropharyngeal suctioning. • Manually move the tongue forward. • Maintain cervical immobilization

  11. Emergency ManagementIntubation Considerations • Avoid nasotracheal intubation: • Nasocranial intubation • Nasal hemorrhage • Consider an awake intubation. • Sedate with benzodiazepines. • Consider fiberoptic intubation if available. • Be prepared for cricothyroidotomy, tracheostomy

  12. Emergency ManagementHemorrhage Control • Maxillofacial bleeding: • Direct pressure. • Avoid blind clamping in wounds. • Nasal bleeding: • Direct pressure. • Anterior and posterior packing. • Pharyngeal bleeding: • Packing of the pharynx around ET tube.

  13. Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular

  14. History • Specific Questions: • vision • Hearing problems • pain with eye movement • areas of numbness or tingling on face • able to bite down without any pain • pain with moving the jaw

  15. Physical Examination • Inspection of the face for asymmetry. • Inspect open wounds for foreign bodies. • Palpate the entire face. • Supraorbital and Infraorbital rim • Zygomatic-frontal suture • Zygomatic arches

  16. Physical Examination • Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. • Inspect nasal septum for septal hematoma, CSF or blood. • Palpate nose for crepitus, deformity and subcutaneous air. • Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

  17. Physical Examination • Check facial stability. • Inspect the teeth for malocclusions, bleeding and step-off. • Intraoral examination: • Manipulation of each tooth. • Check for lacerations. • Stress the mandible. • Tongue blade test. • Palpate the mandible for tenderness, swelling and step-off.

  18. Angle classification of occlusion. A. Clas I, normal occlusion, B. Class I, retroocclusion or mandibular deficiency, C. Class III, prognathic (maxillary deficiency or mandibular excess

  19. Physical Examination • Check visual acuity. • Check pupils for roundness and reactivity. • Examine the eyelids for lacerations. • Test extra ocular muscles. • Palpate around the entire orbits.. • Examine the cornea for abrasions and lacerations. • Examine the anterior chamber for blood or hyphema. • Perform fundoscopic exam and examine the posterior chamber and the retina.

  20. Physical Examination

  21. Physical Examination • Examine and palpate the exterior ears. • Examine the ear canals. • Check neuro distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves.

  22. Radiographic Examination Caldwell Waters Towne Lateral

  23. Submentovertex Occlusal Panorex Apical

  24. Ct Scan

  25. Treatment • The goal management is near-total or total initial reconstruction of the bony architecture Facial buttresses system • Immediate reconstructions are usually less difficult and more successful than delayed reconstructions • Treatment must be individualized • Generally  Soft tissue 8 -12 h, Suturing h & N delayed up to 24 h, Reduce facial fractures within 10 – 14 days

  26. Treatment Recontruction • Use occlusion as a guide • Generally stabilize first mandible, zygoma, maxilla and palate Principle Reduction and Fixation Approach Open or close reduction / fixation Material Alloplastic, Allogeneic and Autologous

  27. Surgical Approach • Coronal • Hemicoronal • Lateral / Medial Eyebrow • Medial Canthus • Temporal • Transconjungtival • Subciliary • Subtarsal • Orbital Rim • Percutaneous • Gingivobuccal

  28. Frontal Sinus/ Bone Fractures Pathophysiology • Results from a direct blow to the frontal bone with blunt object. • Anterior/Posterior wall • Associated with: • Intracranial injuries • Injuries to the orbital roof • Dural tears Clinical Findings • Disruption or crepitance orbital rim • Subcutaneous emphysema • Associated with a laceration

  29. Frontal Sinus/ Bone FracturesDiagnosis • Radiographs: • Facial views should include Waters, Caldwell and lateral projections. • Caldwell view best evaluates the anterior wall fractures. • CT Head with bone windows: • Frontal sinus fractures. • Orbital rim and nasoethmoidal fractures. • R/O brain injuries or intracranial bleeds.

  30. Frontal Sinus/ Bone FracturesTreatment • Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery. • Patients with depressed skull fractures or with posterior wall involvement. • IV antibiotics. • Tetanus. • Surgical management

  31. Surgical management • Intranasal cannulation • Frontal sinus trephination • Osteoplastic flap • Sinus ablation (obliteration) • Cranialization • Reduction and fixation

  32. Frontal Sinus/ Bone FracturesComplications • Associated with intracranial injuries: • Orbital roof fractures. • Dural tears. • Mucopyocoele. • Epidural empyema. • CSF leaks. • Meningitis.

  33. Naso-Ethmoidal-Orbital Fracture • Fractures that extend into the nose through the ethmoid bones. • Associated with lacrimal disruption and dural tears. • Suspect if there is trauma to the nose or medial orbit. • Patients complain of pain on eye movement.

  34. Naso-Ethmoidal-Orbital Fracture • Clinical findings: • Flattened nasal bridge or a saddle-shaped deformity of the nose. • Widening of the nasal bridge (telecanthus) • CSF rhinorrhea or epistaxis. • Tenderness, crepitus, and mobility of the nasal complex. • Intranasal palpation reveals movement of the medial canthus.

  35. Naso-Ethmoidal-Orbital Fracture • Imaging studies: • Plain radiographs are insensitive. • CT of the face with coronal cuts through the medial orbits.

  36. Fracture Classification (MARKOWITZ, 1991) • TYPE I : • A SINGLE NON COMMINUTED • CENTRAL FRAGMENT • NO MEDIAL CANTHAL TENDON • DISRUPTION • TYPE II: • COMMINUTION OF THE CENTRAL • FRAGMENT • NO MEDIAL CANTHAL TENDON • DISRUPTION • TYPE III : • SEVERE CENTRAL FRAGMENT • COMMINUTION • MEDIAL CANTHAL TENDON • DISRUPTION

  37. Surgical Treatment • Reconstruction of the nasal framework • Fixation of the medial canthal ligament • Reconstruction of the associated facial fractures • Overcome the concomitan problems (epiphora, csf leak, etc) • Access to NOE through existing lacerations, bicoronal flap, or local incisions

  38. KILLIAN INCISION FRACTURE EXPOSURE Surgical Treatment MINIPLATES FIXATION

  39. Nasal Fractures • Injuries may occur to other surrounding bony structures. • 3 types: • Depressed • Laterally displaced • Nondisplaced • Clinical findings: • Nasal deformity • Edema and tenderness • Epistaxis • Crepitus and mobility

  40. Nasal Fractures • Diagnosis: • History and physical exam. • Lateral or Waters view to confirm your diagnosis. • Treatment: • Control epistaxis. • Drain septal hematomas.

  41. Nasal Fractures • Treatment • Restoration of form and function • Proper reduction of nasal fractures • Closed reduction for simple fractures • Open reduction for severely displaced fractures • Correction of medial canthal ligament disruption • Correction of lacrimal system injuries

  42. Orbital Blowout Fractures • Occur when the the globe sustains a direct blunt force • 2 mechanisms of injury: • Blunt trauma to the globe • Direct blow to the infraorbital rim

  43. Orbital Blowout FracturesDiagnosis • Periorbital tenderness, swelling, ecchymosis. • Enopthalmus or sunken eyes. • Impaired ocular motility. • Infraorbital anesthesia. • Step off deformity

  44. Orbital Blowout FracturesImaging studies • Radiographs: • Hanging tear drop sign • Open bomb bay door • Air fluid levels • Orbital emphysema • CT of orbits • Details the orbital fracture • Excludes retrobulbar hemorrhage. • CT Head • R/o intracranial injuries

  45. Orbital Blowout FracturesTreatment • Blow out fractures without eye injury do not require admission • Tetanus • Prophylactic antibiotics • Avoid valsalva or nose blowing • Patients with serious eye injuries should be admitted to ophthalmology service for further care.

  46. Orbital Blowout FracturesTreatment Best done 7 – 10 days Numerous materials have been used for bone graft alloplastic, allogeneic and autologous material Surgical approach : Transantral External approach Transconjunctival Subcilliary Subtarsal Orbital rim

  47. Zygoma Fractures • The zygoma has 2 major components: • Zygomatic arch • Zygomatic body • Blunt trauma most common cause. • Two types of fractures can occur: • Arch fracture (most common) • Tripod fracture (most serious) • Can fracture 2 to 3 places along the arch • Lateral to each end of the arch • Fracture in the middle of the arch

  48. Zygoma Tripod Fractures • Tripod fractures consist of fractures through: • Zygomatic arch • Zygomaticofrontal suture • Inferior orbital rim and floor

  49. Zygoma Tripod FracturesClinical Features • Clinical features: • Periorbital edema and ecchymosis • Hypesthesia of the infraorbital nerve • Palpation may reveal step off • Concomitant globe injuries are common • Palpable bony defect over the arch • Depressed cheek with tenderness • Pain in cheek and jaw movement • Limited mandibular movement

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