Trauma

D3 Seminars

Kenneth Fleisher, DDS, FACS

Clinical Professor, Department of Oral and Maxillofacial Surgery
New York University College of Dentistry
 Objectives

n Initial assessment
n Evaluation of oral and facial trauma
• Teeth
• Fractures (mandible, maxilla)
• Soft tissues
n Management
• Options
• Complications
Cartoon shows character of a pt who had conventional tx of panfacial injuries in the 1940s
• based on what you see here, the rationale for treating pts in such a way can only be attributed to
the complexity of facial injuries
• very challenging conditions to treat
◦ what makes these injuries so challenging?
‣ the many vital structures that we have to work around such as IAN, mental nerve, facial
nerve, lingual nerve
• work around eyes for orbital fractures
• work around brain and ears for subcondylar fractures
• work around carotid vessels when we're approaching these injuries extra-orally or
transcutaneously
• work around submandibular and parotid glands

Primary Survey: you're 1st on the scene in the ER to evaluate this pt

• have to ask yourself, what are my IMMEDIATE concerns?
◦ potential life-threatening injuries
◦ think about the ABCs:
‣ airway
‣ breathing
‣ circulation
• might see bleeding so we will need to control bleeding w/ pressure dressings, pack
wounds to prevent hypotension problems
◦ after ABC, the next is Disability which is neurologic status and assessment of pts
neurologic status and evaluation of the cervical spine is completed in the phase
‣ forces severe enough to cause fractures of the facial skeleton are often transmitted to
the cervical spine so remember that careful palpation of the neck to assess possible
areas of tenderness suggest it's a cervical spine injury
‣ pain is the most common symptom in the non obtunded patient
‣ neck should be temporarily immobilized until next injury has been ruled out
‣ ruling out a neck injury remains an essential component of the initial evaluation of the
trauma patient
‣ pt w/ an oral facial trauma is assumed to have a cervical spine injury until otherwise
cleared
◦ after disability is Exposure- looking for other injuries

Secondary Survey: consists of a comprehensive hx, physical exam, imaging, imaging of spine for
trauma as well
• will talk about secondary survey in a bit
 Initial Assessment of the Trauma Patient

n Primary survey?
n Secondary survey?
 Airway

n Head tilt and chin lift

n Endotracheal tube
n Surgical
• Cricothyroidotomy (1st choice)
• Tracheostomy
Establishing an airways or maintaining the airway is the
highest priority when we assess these patients initially
• have to ensure patent airway & that lungs are
adequately ventilated
• injuries to the facial region may involve soft tissues
that may cause an obstruction (ie. injury to the
tongue, neck or larynx) and compromised breathing
• severe mandible fractures (especially bilateral) or
comminuted fractures can cause posterior
displacement of the mandible and tongue which
results in obstruction of the airway
Head tilt and chin lift brings the tongue out of the airway
• but you have to ask yourself, what if the pt has suspected cervical neck injury? we generally use
jaw thrust w/o a head extension but if we have to, we have to (ie. if the jaw thrust does not open
the airway)
Endotracheal tube will help stabilize the airway
• if not, we can think about a surgical airway (ie. cricothyrotomy or tracheostomy)
• cricothyrotomy is more straight forward than tracheostomy

• this patient was intubated after trauma due to di culty breathing

• what do you think is the cause of her complaint?
◦ she has a tooth in the airway
‣ luckily she was intubated and it ended up in the esophagus but it could have ended up
in the lungs
◦ unlike swallowing a foreign body which is usually asymptomatic, the signs and symptoms of
foreign body aspiration can vary according to the level of obstruction and size of the foreign
body
Airway
 Disability
Pupil Responsiveness

Glasgow Coma Scale AVPU Score

Disability or neurologic status which can be assessed by pupil response, the glasgow coma
scale, or the AVPU score:
• pupil response provides a quick assessment of cerebral function
• Glasgow coma scale is used to identify the severity of head injury
◦ 3 variables included are:
‣ best motor response
‣ best verbal response
‣ eye opening
• AVPU score is generally a rapid system of assessing and recording level of consciousness
• when an intracranial injury is suspected, CT scans can be quickly and easy to use to identify
intracranial hemorrhage or contusions or foreign bodies and even skull fractures

Case #1: you're called to the ER to evaluate this pt

• what do you see?
◦ the diagnosis here is anisocoria which is asymmetric pupils
◦ this represents intracranial bleeding/bleeding in the brain parenchyma
◦ other brain hematomas present w/ di erent signs and symptoms
‣ ie. epidural hematomas: classic presentation is loss of consciousness after the injury
followed by a lucic interval and then neurologic deterioration
‣ subdural hematomas: physical exam may demonstrate a focal motor defect,
neurologic defects, lethargy or an altered consciousness
Case #1

What do you see? What does this represent?

 Case #2

What do you see? What does this represent?

left is a battle sign which is

ecchymosis behind the ear
right is a raccoon sign
• they represent a basal skull
fracture at the petrous part of
the temporal bone
START HERE
Case #3
Case #3: Teenager who underwent primary survey by the ER physician
What do you want to know? Starting w/ the secondary assessment
• changes in the pts vital signs, respiratory and circulatory status, neurologic functions since he
arrived, and since the primary evaluation was completed
• if not, since all those are consistent and stable, you can move on to your subjective and
objective evaluation:
◦ history of present illness (when, where, how did this happen)
◦ think about getting imaging or an x-ray in this case
◦ want to know if he hit his head, was there loss of consciousness, signs of confusion
A lot of controversy remains about indications for head CT scans
• it should be performed in:
◦ pts w/ seizure activity
◦ pts w/ unconsciousness lasting more than a few minutes
◦ if they have abnormal mental status
◦ if they abnormal neurologic evaluation
◦ any clinical evidence of skull fracture
• so the use of the CT scans has been suggested for patients even with?? trauma and those who
experienced ANY loss of consciousness or mild amnesias even with normal neurological ndings
• this patient complains of a malocclusion associated w/ soft tissue injury- what is your diagnosis?
◦ We see displaced teeth both clinically and radiographically
◦ extrusive luxation of tooth #23
◦ lateral luxation of tooth #24 through #26
◦ another di erential dx is alveolar fractures based on the x-rays widening of the PDL space
‣ the involved teeth 23-26 are mobile as a group meaning when you touch one or 2 teeth,
the whole segment moves --> this is pathognomonic for dentoalveolar fracture
◦ mandibular fracture
• obv need to get additional imaging like a pan or CBCT or combinations
• next Q: how would you manage this patient?
◦ his hint to us: splinting techniques
 ◦ so we evaluate the patient, pull back the soft tissue, notice
the denuded roots
◦ what else do you think this patient needs?
Examination ‣ a teeth with denuded root apices within a dentoalveolar
fracture should undergo endodontic tx w/i 2 weeks if
possible to prevent in ammatory rxn and infection
 Splints

n Semi-rigid 24G Wire Composite

• Acid-etch composite resin with
üWire (28-gauge; up to 0.4
mm diameter)
üNylon fishing line (up to 0.25
mm diameter)
n Rigid
• Arch bar Essig
• Acid-etch resin wire (24-gauge)
composite splint
• Essig splint (±acrylic)
the dentoalveolar fracture here can be stabilized w/ a few di erent types of splints
• semi-rigid
• rigid
◦ we usually think about rigid types of splints for this type of injury**
◦ ie. arch bars, acid etch resin wires, wire composite splint
◦ rarely use essig splint
‣ consist of 24G stainless steel wire passed labially and lingually around a selection of
the dental arch extending a few teeth on either side that are stable so you want to
extend it out almost like casting a bone
• You should remember that there are certain complications associated w/ the use of rigid xation
even though I would use rigid xation for this injury b/c it's a dentoalveolar fracture
◦ Non-rigid material allows some physiologic movement of the involved tooth so that
ankylosis of the tooth may be prevented and that's a big problem w/ a rigid xation is
ankylosis of the teeth
Think about reduction and rigid immobilization for 4 weeks using some of those rigid splints that he
just mentioned
• closed reduction is done w/ digital manipulation
• open reduction he just showed us previously b/c the fractures were displace and oftentimes the
segments cannot be reduced by closed reduction, & you will have to open it up
Think about a Tetanus booster here
• if there's contamination w/ road debris and dirt
Antibiotics & chlorhexidine rinse
 Follow Up

What should you look for?

n Root resorption
n Vitality of teeth (e.g., pulp necrosis)
n Loss of supporting bone
 **Know the STABILIZATION TIMES- in the
podcast handout
these times are the most up-to-date and
Stabilization Quiz evidence-based
studies have shown that the more rigid and the
longer the duration of stabilization, the more
root resorption can be expected
Dentoalveolar Injury Duration of Immobilization
Concussion ?
Subluxation (mobile tooth) ?
Intrusive luxation ?
Extrusive luxation ?
Lateral luxation ?
Root fracture (apical third, mid-third) ?
Root fracture (cervical third) ?
Avulsion: Replanted tooth (mature) ?
Avulsion: Replanted tooth (immature) ?
Dentoalveolar Fracture ?

Fonseca RJ, et al; Oral and Maxillofacial Trauma, 4th Edition, 2013
Fouad AF, et al; Dental Traumatology 2020
Levin et al; Dental Traumatology 2020
Case #4
Here is an 8 y/o who he treated many years ago for a dog bite by a labrador retriever
What are you concerned w/ for this pt?
• bite marks so you have to think about rabies, tetanus, wound infections like Pasturella multocida
and staph or even strep
• what about the tooth avulsion- how to treat that
◦ rigid splinting
• referral for endodontic consult to determine if these procedures are warranted, or if any of them
are warranted or all of them
◦ for a mature tooth w/ a closed apex, what do you recommend?
‣ A: RCT
◦ for an open apex
‣ A: not as clear; have to think about certain tx options such as apexogenesis,
apexi cation and revascularization
• when we think about root resorption:
◦ root resorption is a major complication w/ traumatic avulsed teeth, usually associated w/
long extra-oral storage times or an unsuitable storage env't at the time of the avulsion
◦ loss of vitality of the PDL in uences the progression of the resorption on the root surface
◦ so unless treated, the in ammatory resorption can result in rapid loss of the reimplanted
tooth as early as 3 months after implantation so appropriate endo therapy can arrest the
resorption process
◦ tx is based on the removal of the source of infection w/ regards to endo therapy
 • He checked w/ Dr. SIggurdson, and these techniques are consistent w/ what we
learn in endo

Endodontic Tx Options for Traumatized Teeth

n Apexogenesis
• Rationale
ü Preservation of vital pulp tissue so that continued root development and apical
closure may occur
ü Poor long-term prognosis of endodontically treated immature teeth
ü Immature teeth have significant repair potential
• Indications: Immature vital tooth due to lateral luxation
n Apexification
• Rationale: Inducing the development of the apical closure (by forming a complete
calcific barrier at the apex) in an immature nonvital tooth with an open apex; minimal
further development of the root is achieved
• Indication: Immature nonvital due to avulsion
n Revascularization
• Rationale: Tissue repair in the nonvital, uninfected, avulsed immature permanent
tooth to promote root development
• Indication: Immature nonvital due to avulsion
n Endodontic Tx
• Rationale: Prevent inflammatory root resorption
• Indication: Mature nonvital tooth due to any dental trauma
Fouad AF, et al; Dental Traumatology 2020
Bezgin T, et al; Dental Traumatology 2015
Case #5

What injuries do you suspect?

• what vital structures are at risk
for this injury?
◦ parotid duct
◦ cranial nerve #7
• blood in the ear may represent
hemotympanum (blood behind
the ear drum)
◦ sometimes blood in the
tympanic cavity in the
middle ear as a result of
basal skull fracture
• how would you repair this
injury?
◦ next slide
Indications to Repair Facial Nerve?
◦ the facial nerve exits the stylomastoid foramen and divides into branches w/i the parotid gland and the
proximal facial nerve injuries posterior to the red vertical line drawn from the lateral canthus should be
repaired using micro-surgical techniques b/c of the signi cant peripheral asthomosis?
◦ repair of facial nerves involving distal branches anterior to the canthus plane is unnecessary so anything
anterior to the red line we generally don't repair
CN VII and Parotid Duct Injury

• Which branch of the facial nerve is injured here?

◦ A: buccal branch which is used for smiling
◦ temporal raised eyebrows
◦ zygmoatic squeezes the eye shut tightly
◦ the marginal mandibular nerve is used for whistling or
puckering the lips
◦ cervical is for contracting the platysma
 • Here I am showing you a lacrimal probe which are useful
in dilating the duct prior to repair w/ a silicone catheter
• this is a silastic or silicone catheter which is placed to
bridge the defect in the duct; the severed ends are then

Parotid Duct Repair sutured over the catheter which is left in place for 10-14
days
• the whole point of catheter is to prevent scarring and
closing o of the duct
• injury to the parotid can lead to leakage of saliva into the soft tissue
• you should know what this is called: a sialocele
• the parotid capsule should be closed to prevent formation of a parotid duct stula or a sialocele
• tx of parotid duct injuries depends on the location of the injury
◦ if the injury involves the PROXIMAL duct while it's still in the gland, the parotid capsules
should be closed and a pressure dressing placed
◦ if the injury is in the MIDPORTION of the duct (kind of like it is here), the duct should be
repaired
◦ if the injury is involving the TERMINAL portion of the duct, it should be drained directly into
the mouth
• What Abx would you use for this pt? good Q**
◦ Augmentin which is recommended for staph coverage

Signs & symptoms of mandible fracture:

• malocclusion, bleeding, ecchymosis, anesthesia, paresthesia, dysesthesia of lower lip,
mandibular movements, changing facial contour, loose or fractured teeth, crepitus b/c the end of
the fractured bones rub together, step deformities of the dentition or inferior border of mandible
Diagnosis:
• left angle fracture
• right parasymphysis fracture
Tx options:
• in this case it was open reduction with internal xation
• plates and screws to xate the mandible
 This pt presents to clinic complaining of jaw pain after
getting into a ght
Case #6

n What are signs and symptoms of a mandible Fx?

n Imaging?
n What is your diagnosis?
n Treatment options?
ORIF
• Open reduction w/ internal xation
• Do you think the surgeon did a good job?
◦ NO: fractured segments on the left are not well approximated
‣ there is a gap in b/w the fractured ends of the bone (blue arrow)
‣ but that can heal if the fracture is stable
◦ a bigger problem: the malocclusion with an open bite on the left (yellow arrow)
‣ in the proper reduction of fractures of tooth bearing bones, it's most important to place
teeth into the pre-injury inter-occlusal relationship
‣ merely aligning and interdigitating the bony fragments at the fracture site w/o rst
establishing a proper occlusal relationship rarely results in satisfactory post operative
functional occlusion
‣ patient's occlusion is most critical**
• How is this complication treated?
◦ look at 3 variables:
‣ malocclusion: minor or major
• minor are not usually appreciated on an x-ray; occlusal adjustment, ortho, etc.
• major- you see them on an x-ray as seen in this pan
‣ time since treatment
• when malocclusion is recognized early, usually less than 3 months, it must be
corrected or mal-union will result
◦ the hardware is removed and proper occlusion obtained via MMF
• in cases of longstanding malocclusion, ie. greater than 3 months, you have to start
thinking about major surgery such as orthognatic surgery to correct the
craniofacial deformity
◦ have to re-fracture the bones and set them in a new position
‣ treatment technique- how the fracture is stabilized
• here, it was treated by closed reduction
◦ if the fracture was treated by closed reduction, you can use elastics to bring
the teeth together so there is a little give here (you can move the bones w/
elastics)
‣ also if it has been less than 3 months since the time of surgery, you can
do that
◦ if the fracture was treated by open reduction internal xation like you see here,
you can't use guiding elastics b/c the mandible is rigidly xed
‣ you can put elastics but it's not going to drag the segments into the
correct bite b/c those plates are resisting the forces of those elastics
 Imaging
n Facial bone Fx: Computer tomography
• Greater resolution than plain films; more
sensitive for Fx detection
ü Small bone fragments
ü Soft tissue details
• Used to rule out injury that cannot be
identified by plain films
• Especially useful for multiple facial
fractures
• 3-D reformatting useful to view gross
disruptions (e.g., comminution)
n Dental injuries: Periapical x-ray preferred
• Others: panorex, CBCT
CT is the most accurate imaging modality for treating mid-face fractures and mandible fractures
often we use panorex for mandible fractures
we use dental radiographs for tooth-related injuries
• unfortunately we usually don't have dental radiographs in the hospital setting
•
 CT May Be Necessary to Rule Out
Subcondylar Fx

this pt had pain in the right

joint
don't see much on the panorex
can see a lot more details on
the CAT scan
diagnosed pt w/ right
subcondylar fracture
bottom is a coronal CT and
that's oftentimes the best way
to diagnose a subcondylar
fracture
Plain Radiographs for Mandible Fractures
Should be able to diagnose each of these types of radiographs:
A) posteroanterior PA radiograph, sometimes called a Caldwell, demonstrates fracture in the
angle area at the arrow
• can see fractures/medial or lateral displacement of the angle, ramus, body and symphysis
• limited views of the condyles which are obscured by the superimposed temporal bone
• not great for visualizing the ramus of the mandible
B) lateral oblique view shows a fracture of the angle at the arrow
• ramus is viewed in this view as well
• posterior body of the mandible
• good for imaging the ramus, angle and posterior body
• limited view of the symphysis and contralateral hemi-mandible
C) reverse-towne view which shows displacement of a subcondylar fracture at the arrow
• ideal for imaging the condyles in the subcondylar region
• generally necessary to specify open mouth reverse-towne view otherwise a standard will not give
as good imaging
D) panorex
 rigid xation --> bicortical
champy plate --> monocortical

Treatment Options
Rigid Fixation: any type of directly applied bone

n Rigid fixation xation that prevents inter-fragmentory movement

between fracture segments when the bone is
under active load meaning chewing
• Bicortical plate Rigid Fixation
• Load bearing
most common semi-rigid
n Semirigid fixation (Champy plate) xation is the Champy plate
functionally stable: applied to those forms of internal xation that are
• Monocortical recognized as not being absolutely rigid like rigid xation w/ bicortical
screws; has micromovement b/c of the bicortical screws but these plates

• Load sharing satisfy the goals of maintaining fragment alignment and permitting healing
during the active use of the bone
Champy Plate
• Functionally stable load sharing: any form of internal xation that is of insu cient
stability to bear all of the functional loads applied across the

n Nonrigid fracture by the masticatory system

• eating forces are shared b/w the hardware and the bone

• Maxillomandibular fixation (MMF)

Non-rigid xation: allows movement b/w the bone fragments
• Wire • interosseous wiring or MMF
• MMF shown on the right
MMF
n Observation
• Often in children with no malocclusion
for most pediatric pt mandible fractures w/o displacement or malocclusion, generally
handled w/ observation, soft diet, and rest
 should be aware of some advantages and disadvantages of each tx modality
especially the ones highlighted in red

ORIF vs Closed Reduction

Rigid Fixation MMF
Advantages • Early return to normal jaw function • Gives occlusion some “leeway” to adjust
• Normal nutrition itself
• Normal oral hygiene after a few days • Short and easy procedure
• Avoids MMF • Biologically conservative (minimally
ü Occupational benefits (lawyers, teachers, invasive; no tissue damage)
salespeople) • No foreign body left in body
ü Seizure disorders
ü Special nutritional requirements
(diabetics, alcoholics)
ü Psychiatric disorders
Disadvantages • Risk to neurovascular structures and teeth • Cannot obtain absolute stability
• Open procedure (more invasive). (contributing to nonunion and infection)
• Need for secondary procedure to remove • Noncompliance from patient due to long
hardware? period in MMF
• “Unforgiving procedure”: the rigidity of the • Cannot use for edentulous patients
plates means no yielding to eventual MMF • Difficult nutrition (weight loss) and oral
or elastic forces if postop movements are hygiene
needed • Possible TMJ sequelae (muscle atrophy
• Greater operator skill (i.e., meticulous and stiffness, myofibrosis)
technique) • Controversial: loss of bite force, reduced
• Scarring (extraoral and intraoral) range of motion
 Indications for Open Reduction
the most common indication for open reduction is displaced unfavorable fractures
most edentulous mandible fractures are treated by open reduction because older pts generally don't
tolerate MMF very well
n Displaced unfavorable Fx (dentate and edentulous)
n MMF contraindicated: epileptics, diabetics, alcoholics, psychiatric patients,
respiratory compromise (e.g., asthma, COPD, emphysema), elderly.
n Comminuted (controversial) – closed reduction (“bag of bone approach”) is less
commonly recommended this pt here is one of his pts that he treated years ago that had a hx of a seizure
see EEG pads on his head
bilateral mandibular fracture of the right subcondylar area
tx by open reduction internal xation
another pt of his tx 6 months ago
she has an edentulous mandible fracture- challenging b/c there is reduced vascularity, little cancellous bone for repair,
reduced healing potential in the elderly, & there's very little bone under the IAN to secure the plate so you need to use a
long plate where the screws are anterior and posterior to the IAN

Open Reduction: Risk of Nerve Injury

the reason why there's reduced vascularity is b/c:

• elderly pop'n loses teeth which is followed by bone atrophy and a relative increase in the
amt of cortical bone --> reduced vascularity and reduced blood ow --> poor healing
we usually treat these by transcutaneous extra-oral approach
however this pt wanted it intra-orally b/c she didn't want any scar on her face or neck so he made a custom plate for her using VSP
• computer simulation
• designed the plate & knew exactly how he wanted the shape and how he wanted it to be adapted
• even put these little guides on the bottom of the plate just to make sure that the plate is secure against the inferior border
• then the plate is fabricated
• this allowed him to do the surgery intra-orally using the custom plate
• the reason he made a CUSTOM plate
◦ you can see one of the complications from open reduction is that we're working around nerves
◦ in this case, the mental nerve
◦ so if he were to treat this pt with a plate o the shelf, he would have to bend it and adapt it, taking it in and out of the patient under that
nerve multiple times, traumatizing the nerve and increasing the risk of permanent paresthesia
◦ by using a custom plate, we reduce the risk to that nerve because all you have to do is put the plate in (don't have to adapt it since it's
already been pre-adapted)
 Closed Reduction of Edentulous Mandible Fx

Dentures with arch bars Gunning splint

ways to treat mandible fractures in edentulous patients non-surgically using what's called Gutting Splints which are essentially base plates that are
made with arch bars on them that you can wire to the zygoma and wire to the mandible
• called circumzygomatic wires and circummandibulo wires
can also wire the patient's dentures in usuing the same approach of wiring to this zygoma and around the mandible and putting arch bars on the
patient's dentures that you could then wire together
 as discussed previous slide, an indication of open reduction is displaced fracture: when fractures are displaced, we're more likely
to open them up and put a plate
how do we determine if a fracture is or will be displaced? understanding muscle attachments and the forces imposed upon the
mandible will aid us in management decisions
fractures are more commonly displaced when they are classi ed as unfavorable

Vertical Favorability
Favorability is determined in 2 dimensions:
• vertical: determined in the medial and lateral plane
by looking at the fracture from either above or below
Favorable as shown here
• horizontal: determined in the superior inferior plane
Unfavorable
by looking at the fracture from the side

• favorable fractures are due to the direction of the

fracture and regulation of the medial and lateral
pterygoid muscle pull that resists displacement so
you can see on the left, it is resisting displacement
based on the angle of the fracture
• on the right, the unfavorable fracture, it's NOT
resisting displacement

Vertical favorability is determined in the medial-lateral plane by

looking at the fracture from either above or below
 Favorable fractures are due to direction of the fracture
and angulation of the masseter muscle that resists
displacement

Unfavorable fractures result in displacement of the

Horizontal Favorability fracture site caused by the pull of the masseter muscle

Favorable Unfavorable

Horizontal favorability is determined in the superior-inferior

plane by looking at the fracture from the side
 This is a 41 y/o male status post suicide attempt by mechanical fall from 40 feet
what type of injury do you suspect here?
• this is a condylar mandible fracture
• CT shows an endotracheal tube at the arrow
• this pt was intubated at the site by the paramedics- why?
Case #7 ◦ in bilateral mandible fractures in the parasymphysis or in the comminuted anterior mandible
fracture, the bone and soft tissues including the tongue are displaced inferiorly and
posteriorly by the pull of the:
‣ digastric
‣ geniohyoid
‣ genioglossus
‣ mylohyoid
‣ ***he only included geniohyoid and genioglossus in the podcast- don't forget the
digastic and mylohyoid muscles

also note the tooth in the airway

this could be obstructing the airway
Debridement

Unfortunately, there was no bone to salvage

he used the large bicortical plate to maintain the position of the
mandible segments, and also the soft tissue envelope for later
reconstruction
one of the big functions of that plate is to maintain the soft
tissue from collapsing**
he did go back and reconstruct the patient about a year later
 post-operatively you can see how these plates are load bearing xation plates
injuries that require load bearing xation are:
• comminuter fractures of the mandible (most commonly)
• fractures where there is very little bony interface due to atrophy (ie. edentulous mandible fracture
shown before)
Postop • injuries that have resulted in the loss of a portion of the mandible that causes defect fractures
◦ the xation device must bridge the are of comminution; there's obviously minimal or no bone
contact here and there's a lot of bone loss
◦ these plates bear all of the forces that are transmitted across the injured area that are generated
by the masticatory system so that's why it's so important
◦ usually they put 3 screws on each side but here they put an extra one (put 4) b/c again this plate
is bearing all of the load
 Case #8
n 27 y/o F 1 day s/p fall
n CC: “I fainted” - What is your differential diagnosis?
n Pt c/o malocclusion, trismus, left preauricular tenderness
n Shift in mandible midline to left
Pt comes in and said she fainted
Why did she faint? What is the di erential dx?
• cardiac-related
◦ arrhythmias
◦ supraventricular tachycardia
◦ ventricular tachycardia
• vasovagal syncope
• hemodynamic
◦ postural hypotension
◦ pulmonary embolism
• CVA
◦ TIA
◦ stroke
• neurological
• epileptic attack
• metabolic
◦ hypoglycemia
◦ dehydration
• drugs
◦ uoxetine
◦ prozac
◦ haloperidol
◦ allopurinol
◦ l-dopa
◦ cinnamon
 What are the signi cant clinical ndings? Should be able to identify that Di erential dx here:
• chin laceration • mandible fracture
• mandible deviated to the left on opening • more speci cally looking at the chin
• ?? reduced on maximum incisal opening laceration --> subcondylar fracture
**in his opinion, if pt comes in with chin
Physical Exam laceration, they are assumed to have a
subcondylar fracture until ruled out

This deviation on opening to the side of the mandibular condyle fracture generally results because the lateral pterygoid muscle
function on the una ected side is not counteracted on the opposite side by the non-functioning lateral pterygoid muscle
Panorex Can see the fracture at the arrow
 Left is coronal CAT scan
Right is a 3D image
You might ask, can we put a plate on this segment? Can we do open reduction interal xation?
• A: NO! there's really not enough room on this type of fracture to put a plate (when it is high at the

CT base of the condyle)

• if it was lower we might consider it
 Maxillomandibular Fixation

We treated her w/ closed reduction

There are 2 primary factors that I determine when I'm thinking about
how long MMF should be:
• age- for most adults he typically recommends 2 weeks at maximum
& then he switches over to nighttime elastics for 2 weeks
◦ purpose of the nighttime elastics is to allow the patient to f'n
during the day and to keep their muscles trained to maintain
their appropriate occlusion at night
• location of the fracture
 There's a lot of data on the duration of MMF that varies on
Historically, a period of 6 weeks of MMF has been used to
• fracture location
allow for healing
• number & severity of mandible fracture
Mandibular growth continues throughout the teenage years
• patient's age
most appropriately managed and most of properly
• patient's health

Duration of MMF
managed fractures remodel the condylar stump closer to
its original form inversely increasing with age at the time of
the injury
• so the younger the child, the more complete the
remodeling
n Uncomplicated Fxs (Noncondylar)1 • as skeletal growth ceases when the patient gets older, so
does its regenerative capacity & only functional
• Children: 2 weeks remodeling is possible in adults
• therefore condylar fractures in children are managed

• Adolescents: 3-4 weeks conservatively and are rarely open

• they usually put them in guiding elastics as opposed to
putting them in MMF
üMinimally displaced Fx: 2 weeks2 • the amt of time that children stay in MMF or tight elastics
before being allowed to function has been decreasing
• Adults: 4-6 weeks over time
◦ secondary to the realization of the therapeutic

n Other factors basically. there's no con rmed

bene t to any period of MMF in a
value during functional movement of the condyle
as bone reacts to the soft tissue forces
surrounding it
• Age child b/c they can remodel
• children <15 y/o generally should be mobilized early and
managed w/ a soft painless diet, guiding
üElderly: Longer MMF (6-8 weeks) maxillomandibular elastics may aid in re-establishing
proper occlusion when an open bite is present

üPediatric: Shorter with noncondylar Fx; no MMF with condylar

Fx (use guiding elastics)3
• Location of Fx – Less time with condylar Fx; more time other Fxs
• Degree of displacement/malocclusion – Longer MMF with
comminuted Fx and major malocclusion
• Compromised healing (e.g., alcoholic) – Longer MMF
• Late treatment – Longer MMF Goodday RHB; OMFS Clin N Am 2013
Adeyema MF, et al; JOMS 2012
1

2
3
Fonseca: Oral & maxillofacial Trauma, 4th Edition 2013
 this is one of his rst pts at
NYU
treated for ankylosis
Risk Factors for TMJ Ankylosis 16 y/o
she is still being treated at
the college
next slide

n Children
• Highly vascularized
• New bone formation
n Trauma
• Damage to
ü Condylar fossa and glenoid cartilage
ü Disc (perforation/displacement)
n Prolonged immobilization (MMF) or muscle
splinting
2 complications unique to pediatric mandibular fractures are:
• risk of TMJ ankylosis
• potential progressive growth disturbances of the face
**trauma is the most common cause ofRTMJ ankylosis and TMJ ankylosis in growing
patients can result in dentofacial deformities

the primary factors contributing to ankylosis after condylar fractures:

• Age- ankylosis is more common in children b/c they have a highly vascularized
condyle and a tremendous ability to make new bone
• Damage to the glenoid fossa and condylar cartilage and maybe perforation or
displacement of the disc
• last factor (tertiary factor) is prolonged immobilization or muscle splinting
He D, et al; JOMS 2014
 Treatment for TMJ Ankylosis

Here are his strategies for this pt:

n Remove ankylotic bone

n Replace condyle with
costochondral rib graft
n Replace disc with temporalis
muscle flap
n Functional considerations
one of the functional considerations is that you have to nd a material strong
enough that can be used as a buttress (blue area in gure) by maintaining the
mandible in a stable position in relation to the cranial base and can withstand
the forces of occlusion
• that's why it's called a buttress b/c it has to withstand these forces
the type of bone needed to repair the defect should be strong like cortical
bone
 Costochondral Harvest

here he used costochondral rib graft

which is mostly cortical bone
 her post-op showing pretty good improved opening

Postop
 Subcondylar Fx:
Open vs. Closed Reduction?

There is no evidence that repair of discs or fixing a fractured condyle in an

upright position prevents arthritis, jaw hypomobility, pain, deviation of jaw
movement, clicking, or the myriad of other morbid complications that can follow
fractures of the mandibular condyle

Walker RV. Condylar Fractures: Nonsurgical Management. J Oral Maxillofac Surg 1994; 52(11): 1185-1188
Here is a pt w/ a symphysis fracture, a right condylar fracture and a left subcondylar fracture
He tx this pt w/ open reduction internal xation of the symphysis, and closed reduction of the bilateral subcondylar fractures
most pts w/ subcondylar fractures are treated by closed reduction even if there's enough room to put a plate where the condyles are displaced b/c
the results are generally pretty good
He most commonly treats these injuries by closed reduction as most OMFS do
He usually tells the pt that if patients do have functional problems with opening, closing, eating, etc., after you have attempted this conservative
approach, he can certainly reconstruct the joint at a later time
 What type of injury is this?
Another type of facial injury:
• ZMC fracture
• the zygoma maintains points
of articulation with the maxilla
• should be able to identify all
these di erent reference
points:
◦ A) greater wing of the
sphenoid at the
zygomatico-sphenoid
suture
◦ B) frontal zygomatic
suture
◦ C) temporal bone at
the zygomatico-
temporal suture
◦ D) zygomatic maxillary
suture
**should be able to identify all
the points of this type of fracture
 Principles for Lip Repair

n Step 1: Local anesthesia

n Step 2: Irrigation
n Step 3: Debridement of crushed, devitalized, necrotic tissue
(uncommon)
n Step 4: Align vermillion border
n Step 5: Layered closure
• Inside-out
1. Mucosa
2. Muscle
3. Dermis
4. Subcutaneous
5. Skin
The lip provides special challenges to repair following trauma b/c the anatomy of the region of the vermillion border which involves the transitional
mucosal tissues of the skin associated with edema of the tissues after trauma to the area is very aesthetic so if you miss the repairing of the
vermillion border, it can have a tremendous aesthetic consequence
Outlined steps for repairing a lip:
1) make sure we use LA; blocks are preferred to local in ltration to prevent unnecessary edema and distortion of the landmarks to be approximated
• in the lower lip, he would use a mental nerve block (penetrate mucous membranes at the site adjacent to the canine and 1st premolar)
• in the upper lip, he would consider an infraorbital nerve block (place needle into height of the mucobuccal fold over the 1st premolar with the bevel
facing the bone)
2) irrigation- usually irrigate w/ normal saline; wound irrigation is likely to be e ective to reduce risk of infection by reducing bacterial inoculum in the
wound; tap water is acceptable on occasion but sterile saline is the best
• do not apply antiseptic or detergents such as chlorhexidine or alcohol or hydrogen peroxide into the wound b/c these solutions are cytotoxic and
may harm normal tissue
• we do all of this b/c: a wound inoculum of 10 to the fth bacteria per gram of tissue has been shown to increase the risk of wound infections so we
are trying to reduce that inoculum
3) debridement- generally debridement of lip lacerations and and perioral wounds should be avoided
• only debris clearly crushed, devitalized, or necrotic tissue
4) vermililion border is closed
• major cosmetic challenge to the repair of a lip laceration is a wound that crosses the vermillion border
• so when preparing this type of wound, the 1st stich must align the edge of the VB exactly
• a mismatch of even a millimeter may be readily noted by anybody looking at the patient
5) for through and through lacerations, the wound should be closed in layers inside out beginning with the mucosa
• the reason why we close the mucosa rst is so that we close o the wound from further saliva contamination and then after the mucosa is closed,
we will move on to the muscle layer, the orbicularis oris, then the dermis, then the subcutaneous tissues and nally the skin
• so generally mucosa is closed w/ real 3-0 or 4-0 chromic
• the muscle is usually also closed w/ 3-0 or 4-0 suture (either chromic or vicryl)
• when you close the dermis and subcutaneous tissues really well, it really brings the dermis well together and there's really not much left to close
on the skin
• skin should be approximated w/ 6-0 nylon or proline (he likes proline b/c it is very non-reactive) but it is usually 6-0 b/c obviously this is on the skin
and we want to reduce the risk of scar)
• so the external oral mucosa can be repaired w/ absorbable suture
• skin is closed w/ interrupted sutures
◦ he does not recommend running sutures; he says interrupted sutures b/c you can get better approximation by placing the sutures
individually --> better cosmetic outcome
Questions?