8. Craniomaxillofacial Trauma

You are called to the ER to suture several facial lacerations including one of the upper lip involving the vermillion border. While you are working, the patient has been complaining of increasing pain in their eye. They now say their vision is getting worse. You note the eye looks like it is bulging outwards. What could this patient be developing? A.) Orbital abscess B.) Hyphema C.) Retrobulbar hematoma D.) Septal hematoma

REWATCH LECTURE

Hyoid bone fractures

Rare Often involves strangling

How do you manage an Alveolar Fracture?

Reduction Fixation Splint removal at 4-6 weeks

How do you manage lateral luxations?

Reduction Fixation if symptomatic Splint removal at 2-4 weeks

How do you treat extrusion?

Reduction Fixation if symptomatic Splint removal at 2-4 weeks

Crown-root fracture, is a fracture involving enamel, dentin, and cementum with or without pulpal exposure. How do you manage them?

Remove segment... and restore Remove segment, endo...and restore Remove segment, endo, ortho extrusion...and restore Remove segment, endo, surgical extrusion...and restore Remove segment, leave in situ...and place dental implant Extraction...and possible bone graft, then implant

Supporting deep tissues

Reticular dermis throughout most of the face Support suture in galea - Dermal sutures can injure hair follicles Tarsal plate must be sutured Typically unnecessary to suture ear cartilage

LeFort 3 Fracture

Separates midfacial skeleton from base of skull Complete separation of midface including nasoethmoidal complex, zygomas, and the maxilla

Ellis Class 1 Fracture

enamel only Smooth enamel Serial pulp testing up to 6 months

How do you treat an Ellis Class 4 Fracture?

extraction OR Reduce, splint, and fixate for 4 weeks

What is a bridal wire?

rewatch lecture

Zygomatic Arch Fractures

rewatch lecture

slide 60

rewatch lecture

LeFort 1 Fracture

separation of the alveolar part of the maxilla from the rest of the face.

Steps to laceration repair

1. Full history and physical (is this possible???) 2. Consent 3. Plan 4. Anesthetize if needed 5. Decontamination 6. Debridement 7. Wound closure

What so you do if a tooth has avulsed in < 2 hours with closed apex?

1. Hanks for 30 minutes 2. Replant 3. Splint for 7-10 days 4. Endo at splint removal 5. Fill with CaOH 6. Gutta percha obturation at 6-12 months

What so you do if a tooth has avulsed in > 2 hours?

1. Replant immediately if possible 2. Transport in Hank's solution or other 3. Sodium hypochlorite for 30 min vs manual PDL debridement 4. Extraoral root canal treatment 5. Citric acid bath for 3 minutes (limits root resorption) 6. 1% stannous fluoride bath for 5 minutes (limits root resorption and inflammation) 7. Doxycycline bath for 5 minutes 8. Replant tooth 9. Splint for 7-10 days

What so you do if a tooth has avulsed in < 2 hours with open apex?

1. Replant immediately? 2. Hanks for 30 minutes 3. 1 mg / 20 cc doxycycline for 5 min 4. Replant and splint for 7-10 days 5. Apexification with CaOHif it develops pathology

Trauma Assessment: What is the Glasgow Coma Scale?

3-15 <9 correlates with high mortality rates Classifies severity of head injury Eyes, motor response, verbal response

Instrument tie: Number of ties (throws) is determined by suture type. 3-4 ties = ? 4-5 ties = ?

3-4 ties for an absorbable suture 4-5 ties for a synthetic nonabsorbable suture

How do you treat mandibular fractures?

4-6 weeks of maxillomandibular fixation (MMF) MMF and semirigid fixation Rigid fixation

You are called to assess a patient in the emergency department with a facial laceration. You note a vertical laceration immediately anterior to the ear and lateral to the lateral canthus of the eye. What structures are you most concerned about? A.) Facial nerve B.) Trigeminal nerve C.) Wharton's duct D.) Nasolacrimal duct

A) Facial nerve

Why do plastic surgeons get such good results?

Clean the wound - Betadine, chlorhexidine, irrigate, irrigate, irrigate - Beware of the eyes! Consideration of MINIMAL excision of irregular skin edges Good closure of deep layers Smaller and only enough sutures in skin

Avulsion

Complete luxation of the tooth out of its socket

Ellis Class 2 Fracture

Dental fracture involving enamel and dentin Glass ionomer cement Reattachment vs composite Serial pulp testing up to 6 months

Ellis Class 3 Fracture

Dental fracture involving enamel and dentin with exposed pulp Is the root completely formed Incomplete: - Pulp capping - Pulpotomy Complete: - Pulpectomy: fully developed roots, no pulpal circulation Treatment can be deferred for up to one week Remove superficial pulp using round bur (2-3 mm depth) Calcium hydroxide seal or MTA

Perform a full head and neck exam

Detailed history and physical exam in a well-lit room Have they had a tetanus shot in the last 10 years? Look for lesions or signs of other injuries Cranial nerves - Has ophthalmology seen the patient yet? - Extraocular movements intact? - Does the facial nerve function properly? Salivary and lacrimal ducts Bony mobility or crepitus

Mandibular fractures

Deviation of the mandible Reduced opening Paresthesia Involving a tooth root

Avulsion: PDL

Do NOT debride the root if within the accepted re-implantation window

Ellis Classification System

Type I- Enamel Fracture Type II- Enamel/Dentin Fracture Type III- Enamel/Dentin Fracture with Pulp Exposure Type IV- Root Fracture *For immature pulp exposures, consider calcium hydroxide and pulpal procedures for apex formation.

Majority of mandibular fractures occur where?

1. Condyle 2. Angle 3. Symphysis

You are coaching a little league baseball game. A player is hit in the mouth with a ball, which completely avulsed her permanent tooth #8. She is 9 years old. She has no other injuries. Which of the following is the best course of action? A.) Immediately insert the tooth back in the socket and go to a dental office B.) Put the tooth in her pocket and seek out the nearest trauma center C.)Put the tooth in tap water and go to the nearest dental office D.) Clean the tooth without touching the root, insert it in the socket, and seek out a hospital with dental care

A) Immediately insert the tooth back in the socket and go to a dental office

A 13 year oldboy presents with lateral luxation and small alveolar bone fracture of teeth 23-26. A splint is applied. How long should this be left in place? A.) Two weeks B.) Four weeks C.) Six weeks D.) Eight weeks

B) Four weeks

LeFort 2 Fracture

Blunt force around nose, entire midface separation

Tetanus

Booster every 10 years Heavy soil, manure, devitalized tissue, deep puncture wounds Tetanus prone wound >>> booster within last 5 years - Might need booster

You are called to the ER to suture a simple facial laceration in a cooperative 16 year oldmale. What is a good choice of suture for closing skin with the best cosmetic result? A.) 2-0 vicryl B.) 3-0 silk C.) 5-0 prolene D.)6-0 chromic gut

C) 5-0 prolene

Avulsion: Time since trauma

Ideal replantation at 20-30 minutes Up to 60-120 minutes acceptable

What do we mean by favourable/non-favourable fractures?

Favourable fractures are when surrounding muscles help pull fracture back together (e.g. angle, where masseter/MP aid closure) Unfavourabe fractures are when surrounding muscles pull fracture apart (e.g. condyle, LP/MP pull away)

Ellis Class 4 Fracture

Fracture involving cementum, dentin, and pulpal tissue

Alveolar Fracture

Fracture of the alveolar process that may or may not involve tooth sockets

Frontal bone fractures

Frontonasal duct drainage

Rank the best mediums to store an avulse tooth from best to worst:

Hank's balanced salt solution ViaSpan - Organ transplant solution Milk - Cannot replenish cellular metabolites - Good before 20 minutes - Ineffective after 6 hours Saliva Saline

Trauma Assessment: What is the secondary assessment?

Head and skull - Lacerations, abrasions, fractures, intracranial bleeding - Prevent increased ICP (HTN, bradycardia) Maxillofacial region - Blood / secretions -> airway compromise - Mandibular fractures - Account for teeth Neck trauma (hematoma, crepitus, carotid pulses) Spinal cord - 55% of injuries in cervical region - Suspected injury? > neutral position, don't move spine or head! Imaging / CT scans

If a tooth has been aspirated, where has it most likely traveled?

Inferior lobe of right lobe, because it has shorter and more vertical right bronchus.

Which suture do you choose?

Intraoral: - 3-0 or 4-0 chromic gut or vicryl Deep fascia - 3-0 or 4-0 vicrylon SH needle Skin - 4-0, 5-0, or 6-0 proleneor nylon on P3 needle - 5-0 fast-absorbing gut in children or patients unlikely to follow up

What is the most sever alveolar fracture?

Intrusion

Intrusion

Inward displacement of the tooth that damages the PDL, bone, or underlying structures

lateral luxations

Lateral eccentric displacement of the tooth in its socket

Maxillary fractures are classified as what?

Lefort 1, 2, and 3

Glue is good for wounds that are...

Linear With viable tissue Hemostatic In children (make sure you tell them it burns!)

Avulsion: Storage since trauma Avulsion: Time since trauma Avulsion: PDL Avulsion: Stage of root development

Maintains viability of periodontal fibers Physiologic pH No antigen-antibody reaction Antimicrobial Sterile Inexpensive Long shelf life Effective under various conditions Reduced risk of root resorption

Trauma Assessment: What is the Primary survey: ABCDE

Management of life threatening conditions

Nasorbitoethmoid (NOE) fractures

Markowitz classification (see image) Telecanthusvs hypertelorism Nasolacrimal drainage

Nasal Bone fractures

Most common Septal hematoma

Scars happen, but we can minimize them

Only epidermis regenerates Dermis and below repairs

Zygomatcomaxillary Complex (ZMC) fractures

Orbital involvement Mandibular range of motion Esthetics

Extrusion

Partial displacement of the tooth out of its socket

Subluxation

Physical injury to the tooth supporting structures with some mobilitybut no fracture or displacement

Concussion

Physical injury to the tooth supporting structures without dental fracture, mobility, or displacement

How do you manage hemorrhages?

Pressure Suture? Cautery (not skin edges) Finger

Teeth in the line of fracture should be extracted if they...

Prevent reduction of the fracture Have fractured roots Have periodontal disease Are grossly mobile Are a partially impacted third molar with periodontal disease Are associated with pathology

Orbital Fractures

Pupils Extraocular movements Vision Pain

Characteristics of sutures

READ IMAGE

How do you manage intrusion?

Surgical repositioning and fixationAcute phase in permanent teeth Orthodontic repositioning Delayed treatment Spontaneous eruption Deciduous / primary teeth with incomplete root formation

Avulsion: Stage of root development

Teeth with open apices > 1 mm have improved prognosis