Trauma: Oral and Maxillofacial Surgical Issues









Note: Baseball/softball and skateboarding have use of protective equipment

This study indicated that fractures from sporting events were reported to most likely occur in 13–15-year-olds (40.7%). Nasal, orbital, and skull fractures were the most commonly sustained fractures in this review. Maxillary (12.6%), mandibular (7.2%), zygomaticomaxillary (4.2%), and naso-orbital-ethmoid (1.2%) fractures were less likely to occur. However, varying distributions have been reported in the literature. Sports-related injuries and distribution of the related fractures vary by region and sport preferences. Studies from abroad have also had high proportions of injuries related to cricket, rugby, handball, equestrian, and martial arts [57].

Changes in sport are exposing the face to more injuries. With the emergence of freestyle skiing and snowboarding, with airborne high-speed maneuvers, facial, head, and neck injuries are on the rise with 245 facial trauma injuries in World Cup events [15]. As with other high-speed injuries, many of these (58) had severe neurotrauma. Competitive platform diving is another example in which changes in sport have resulted in new types and patterns of injury, such as orbital and sinus fracture from high-speed impact with the water [16]. Deepwater exploration in scuba diving can potentially cause temporomandibular joint dysfunction or barodontalgia [17].

There is continued emphasis on prevention of injuries in sports. The use of protective gear including helmets, face masks, and mouth guards is endorsed for decreasing injury rates. The effectiveness of these measures is mostly positive, but there is evidence that helmeted participants in sport are more likely to employ risky behaviors. Distracted cycling is an emerging concern along with the rates of helmet use [18]. Protective gear promotes the perception of safety and can cause the participant to minimize risk [19]. This may partially explain why the use of protective gear is variable in its impact on injury reduction.

5.2 Evaluation of Patients with Facial Trauma

Evaluation of Patients with Facial Trauma

  • Immediate assessment

    • Advanced trauma life support (ATLS)

  • History and physical examination and acute care

  • Imaging

5.2.1 Immediate Assessment

The initial assessment of facial sports injuries must follow the recommendations of the American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) management to assess systemic, potentially life-threatening emergency. Injuries seemingly isolated to the face are commonly associated with neurotrauma, cervical spine injury, and pulmonary barotrauma. Treating providers must remember the systematic evaluation of airway, breathing, circulation, and disability (ABCDs) of ATLS trauma management [20]. Careful attention should be turned to assuring a patent airway (A). If an injury to the patient’s cervical spine is suspected, the patient’s cervical spine should not be manipulated. Per ATLS protocol, patients with maxillofacial injuries or head trauma should be presumed to have a cervical spine injury, and the neck should be immobilized until fully evaluated [20]. The provider must also assure that breathing (B) is unobstructed and that circulation (C) is maintained. Any life-threatening hemorrhage should be managed at this point in time. It should be remembered that highly conditioned athletes might not have the same physiologic response (i.e., tachycardia) to blood loss that the normal population may have [20]. The patient should then be evaluated for any neurologic deficit (D—Disability) with a focused neurologic exam including level of consciousness, orientation to person, place, and time, visual acuity, pupillary size and reactiveness, visual changes, or numbness or weakness in the extremities. Glasgow Coma Scale (GCS) assessment of patients with a head injury will assist in developing an evaluation and triage plan for the patient. Facial fractures, particularly high-energy zygoma and midface fractures, are associated with lower GCS scores and cervical spine injuries [21]. Concerning symptoms include loss of consciousness, altered consciousness, nausea, or vomiting. If a head injury is suspected, prompt transfer to a medical facility for neurosurgical consultation is recommended. Again, it is imperative that cervical spine precautions be maintained in the transport period.

Many concomitant injuries are noted along with maxillofacial trauma. The treating provider must have a high suspicion of index of other injuries whenever a patient presents with facial trauma. Allareddy et al. [12] reported common associations with intracranial injury (12.3%), skull fractures (7.2%), and spinal cord injury (0.2%). Cervical spine injuries (2.6–6.5%) have also been associated with facial fractures [22, 23].

5.2.2 History and Physical Examination and Acute Care of Facial Injuries

Once the patient has been evaluated with the primary survey in a systematic fashion and it has been noted that he or she is stable from a cardiorespiratory standpoint and intracranial injury or cervical spine injury has been ruled out, the secondary survey should then be completed. This involves completing a review of the patient’s history and performing a thorough physical examination. Obtaining a patient’s history can be performed in the AMPLE (A, allergies; M, medications; P, past history; L, last meal; E, events/environment related to the injury) format [20]. Pertinent findings in the medical history should be noted and discussed with any subsequent providers.

The physical examination should be performed in a systematic and thorough manner. The head and neck exam will evaluate for facial asymmetry. The skin of the head and face is then evaluated for abrasions, lacerations, or contusions. The forehead is examined for symmetry, depression, or neurosensory changes. As the exam moves inferiorly, the eyes are palpated for steps of the orbital rims, pupillary size, light reactivity, peri- orbital ecchymosis, subconjunctival hemorrhage, chemosis, extraocular eye movements, visual acuity, diplopia, entrapment, or enophthalmos. Enophthalmos, steps of the orbital rim, or entrapment are indicators of orbital fractures. If entrapment (limitation of the movement of the globe) is noted, the patient should be referred for immediate surgical evaluation. Additionally, if bilateral periorbital ecchymosis (i.e., “raccoon eyes”) is noted, there may be an injury to the anterior cranial fossa, frontobasilar injury, and naso-orbital-ethmoid or Le Fort fractures. Any concern for fracture should prompt a referral for further evaluation.

The external ear evaluation is also important [24]. The region is evaluated for lacerations or hematoma formation. Left untreated, a hematoma can lead to permanent deformity, such as “cauliflower ear.” The external auditory canal should be inspected and the tympanic membrane evaluated for perforation or hemotympanum (blood along the tympanic membrane). Any changes in hearing should be noted. When evaluating the mastoid region, the examiner should be mindful that if there is any bruising in this region (i.e., Battle’s sign, [25]), it may indicate a basilar skull fracture.

Nasal fractures have been reported to be the most common sports-related facial fracture [14]. Therefore, a thorough nasal evaluation should also be performed. Epistaxis in the sports injury patient is a nasal fracture unless proven otherwise. The dorsum should be evaluated for deviation or crepitus. The septum is evaluated for a septal hematoma or deviation. Septal hematomas will require prompt treatment in order to prevent the possibility for necrosis and subsequent septal perforation. This may ultimately lead to a saddle nose deformity [26]. Epistaxis may be initially managed with compression; if this is unable to manage the initial hemorrhage, the patient should be referred to a facility for further management with anterior or posterior nasal packing as indicated. Within this region, the midface is palpated for stability or depression along the malar (cheek) region, zygomatic arch, and maxilla.

An oral evaluation is then completed. The mucosa is examined for lacerations. Teeth are evaluated for fractures, avulsions, and/or mobility. The maxilla is assessed for stability via manual palpation for mobility and assessment of occlusion. Clenching the teeth may reveal vertical instability associated with maxillary fracture. The patient’s occlusion (bite) is evaluated. Any changes in occlusion and fractured, missing, or loose teeth should be noted and referred for further clinical and radiographic evaluation. Any missing teeth should be accounted for in the immediate area; otherwise a chest radiograph should be obtained to rule out aspiration. The mandible is put through an active range of motion; any mobility of mandibular segments, occlusal steps, floor of mouth ecchymosis, bony steps along the inferior border, gingival lacerations, (◘ Fig. 5.1), or trismus (limited opening) is concerning for mandibular fracture.

Fig. 5.1

Clinical findings consistent with a mandibular fracture. Floor of mouth hematoma, gingival laceration, and occlusal step in the interproximal region of teeth 23 and 24

Temporomandibular joint (TMJ) evaluation is for the purpose of diagnosing both hard and soft tissue injuries of the temporomandibular joint. Inspection of the mandible may demonstrate preauricular facial edema in the patient with TMJ injury, such as contusion or fracture of the condyle. Bleeding from the external auditory canal may be a finding in tympanic plate (posterior glenoid fossa) fracture or in hemarthrosis. Open bite on the ipsilateral to the side of injury is a sign of hemarthrosis or lateral dislocation of the condyle. Ipsilateral occlusal prematurity in the molar occlusion and deviation to the side of injury on opening and protrusion are signs of condylar or subcondylar fracture. Articular disc displacement or tears can occur in concussive and deceleration injuries. Tenderness on lateral capsule TMJ palpation and with gentle digital pressure in the anterior portion of the external auditory canal is associated with capsular tears of the articular disc. Due to edema, clicking of the disc is rarely noted in the examination shortly following injury when the disc is torn but often emerges in the days after which acute edema has abated. Anterior disc displacement without reduction can cause immediate mandibular hypomobility. Contusion of the muscles of mastication as well can produce hypomobility. These injuries may be isolated or concomitant.

Open lock (when the patient is unable to close the jaw) may be related to mandibular dislocation or due to spasm of contused muscles. The patient may require mandibular reduction with inferior and posterior pressure on the external oblique ridge of the mandible. Because of the possibility of associated fractures, when practical, preoperative imaging of the injury is often utilized. The patient with open lock normally benefits from sedation with a short-acting benzodiazepine, such as Versed, to allow for completion of this maneuver.

Increased pain on biting (i.e., a tongue blade) may be indicative of a mandibular fracture. If an intraoral laceration approximates the region of the parotid ducts or submandibular ducts, one should attempt to express saliva from the respective gland to assess for ductal injury. Paresthesias in the upper lip and cheek (cranial nerve (CN) V2 distribution) may indicate an orbital floor or maxillary fracture. Paresthesia in the lip or chin (CN V3 distribution) may indicate a mandibular fracture.

Further neurologic evaluation of the patient with a maxillofacial injury includes a thorough cranial nerve exam testing visual acuity (CN II), pupillary responses (CNs II and III), and ocular motility (CNs III, IV, VI). The trigeminal nerve (CN V) controls facial sensation, the muscles of mastication, anterior digastric, mylohyoid, tensor tympani, and the tensor veli palatini. Facial sensation in the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches should be examined with a light touch. Facial movement can be evaluated along the branches of the facial nerve (CN VII). Raising the eyebrows tests the temporal (frontal) branch. Tight eye closure tests the zygomatic branch. A smile is used to evaluate the buckle branch. A frown or lip pucker is used to evaluate the marginal mandibular branch [24]. Function of the patient’s hearing should be evaluated (CN VIII). This can be accomplished with a finger rub bilaterally. Palatal elevation and symmetric position of the uvula are also evaluated (CNs IX and X). Shoulder shrug (trapezius innervation) or head turn (sternocleidomastoid innervation) are evaluated for any asymmetries (CN XI). Finally the tongue is protruded (CN XII), and any asymmetry should prompt further evaluation. Following completion of the focused history and physical, referral and imaging (if indicated) should then be obtained.

5.3 Imaging of Facial Trauma

Different types of facial fractures have been described below (► Sects. 5.4 and 5.5). Ideal imaging depends on the initial clinical diagnosis of the trauma.

Mandibular Facture

A panoramic radiograph is the best initial examination to evaluate mandibular fracture. Radiographic appearance of mandibular fracture can be of three types: (1) a linear radiolucency limited to the bony outline of the mandible indicating separation of the fracture fragments, (2) a linear radiopacity limited to the bony outline of the mandible indicating overlapping of the fracture fragments, and (3) a step deformity in the outline of the mandible. For fracture diagnosis, the mandible is considered as a ring that often fractures in two different places, e.g., subcondylar fracture may be associated with a fracture of the contralateral parasymphysis. In addition to a panoramic radiograph, a CBCT scan is particularly helpful in determining displacement of a fractured condylar head. Plain film radiographic examinations, such as open-mouth Towne’s view or transorbital view, have been replaced by CBCT or CT scans. An MRI is useful when an edema is suspected in the temporomandibular joint or when multiple fractures are present in the facial skeleton in addition to mandibular fracture.

If healing is uncomplicated, postreduction evaluation of the mandibular fracture is best performed by panoramic radiography, particularly when metallic hardware is used. In case of suspicion of infection or inadequate reduction, cross-sectional views from a high-resolution (0.1–0.2 mm) CBCT scan can help to rule out periosteal new bone formation. A CBCT scan is also helpful in identifying the relationship of metallic screws of bone plates with the inferior alveolar canal. Compared to a CBCT scan, a CT scan is likely to generate extensive image artifacts when metallic bone plates are present.

Midface Fracture

Midface fracture provides challenging radiographic findings, due to the presence of multiple bones, sutures, and critical structures in the midface region. Panoramic radiography is moderately useful in determining fracture involving the zygomatic processes and floors of the orbits. Most plain film radiographic examinations only provide minimal information on the complex anatomy of the maxillofacial skeleton. Although a CBCT scan of the maxillofacial trauma can provide adequate information of the bony fractures, it does not provide reliable data on the soft tissue status. In contrast, CT images in soft tissue and bone algorithms are most useful to evaluate midface trauma. Optimal protocols for CT imaging should include 0.6–1.2-mm-thin slices in axial and coronal orientation with 3D reformatting. The field of view should extend from the frontal sinus to the inferior border of the mandible. An MRI should be acquired when there is suspicion of trauma to the brain tissues and if there are penetrating wounds. Imaging for brain tissues is beyond the scope of this text.

Each imaging study for maxillofacial trauma should accompany a thorough radiology report that identifies the location and extent of the fracture(s), whether favorable or unfavorable, critical structures that may be involved, dental tissues that may be in the path of the trauma, any dental fracture in addition to jaw fracture, and recommendation for further imaging. To assist the surgeon in proper planning, 3D reconstruction of the CT or CBCT data should be provided in addition to multiplanar reconstruction.

5.4 Mandibular Fractures

5.4.1 Classification

Of all facial fractures related to sports, 7–41% [6, 7, 14, 13] of these fractures occur in the mandible. The site of mandibular injury is related to the mechanism. The type of injury will vary depending on the circumstances at the time of the injury and the force sustained by the participant. Common mandibular injury locations have been described by several sources [3, 11, 12, 27, 13]. Fractures may occur at the condyle, ramus, coronoid process, angle, body, alveolus, or symphysis. Antoun and Lee [13] evaluated the distribution of mandibular fractures in sports-related maxillofacial fractures in New Zealand, and the angle was noted to be the most frequently affected region (◘ Fig. 5.2). When evaluating and treating mandibular fractures, it is important to consider other possible injuries. If one mandibular fracture is noted, there is a high probability of a second fracture [28]. Additionally, cervical spine injuries (5.1%) can be encountered even with isolated mandibular fractures [23].

Fig. 5.2

Distribution of sports-related mandibular fractures in the condyle (25.3%), ramus (2.4%), angle (34.7%), body (13.8%), and parasymphysis/symphysis (22.9%) [13]

When diagnosing fractures, they can be categorized by the type of fracture. Often, when children sustain mandibular fractures, they can occur in a greenstick fashion (◘ Fig. 5.3a), meaning they are incomplete. Simple fractures are a complete separation of two pieces of the bone (◘ Fig. 5.3b). When multiple fragments of bone are present at the fracture site, this is termed comminuted (◘ Fig. 5.3c). A compound, or open, fracture communicates with the external environment via skin or oral lacerations (◘ Fig. 5.1). Fractures that occur in the region of the teeth are also considered open fractures due to communication to the oral cavity through the periodontal ligament.

Fig. 5.3

Diagram and 3D CT reconstructions demonstrating a a greenstick (incomplete) mandibular fracture, b a simple mandibular angle fracture, and c a comminuted mandibular fracture

If the fracture is reduced by the muscle pull of the mandible in relation to the geometry of the fracture, it is considered to be a favorable fracture. If the bones are further displaced by the muscle pull, the fracture would be considered unfavorable (◘ Fig. 5.4).

Fig. 5.4

Demonstration of masseter pull (red hash with bold arrow) on a favorable and b unfavorable fractures

Lastly, if one wishes to evaluate severity of mandibular injuries in a more objective fashion, there are tools to do this. The mandibular injury severity score was developed to address this need [29]. This scale has been used since its development in areas of research.

5.4.2 Treatment of Mandibular Fractures and TMJ Injuries

The goal of treatment of mandible fractures is directed toward restoration of form and function at the fracture site. In the mandible, this includes the restoration of the patient’s occlusion along with the ability to eat and speak. For all patients, but especially the athlete, return to immediate full function of the mandible is advantageous. It is important to do all of these things while providing the patient with minimal inconvenience and maximum esthetics.

Timing of repair is variable and is highly dependent on any associated injuries or medical comorbidities. These concerns must be addressed prior to proceeding with treatment. Generally, it is preferred to treat fractures in a timely manner. Postoperative edema, typically peaking at 48–72 h following the injury, may complicate surgical access and reduction. The treating surgeon must consider this fact. Most mandibular fractures are compound fractures, communicating with the oral cavity or the skin. The most typical site of communicating to the external environment is via the gingival sulcus in the dentate portion of the mandible. These, as well as compound fractures through the skin, are at higher risk of infection if treatment is delayed. Antibiotics covering oral and skin flora, as appropriate, and an antimicrobial rinse (i.e., Peridex 0.12%) are recommended beginning at the time of patient evaluation.

Treatment principles of fractures include fracture reduction and immobilization. This can be completed in several ways in the mandible. Patients may be treated closed (i.e., without incisions) or open. Internal fixation is typically provided with plates and screws. Internal fixation provides fixation forces across the fracture site to permit undisturbed healing with an early return to function. Closed treatment provides immobilization of the entire body part with maxillomandibular fixation. The treatment chosen depends on the age and physical status of the patient, type of injury, patient desires, local anatomic factors, and risks of treatment.

Closed reduction was originally used with a bandage, known as the Barton bandage [30]. This gave way to wiring techniques to align the teeth into the proper occlusal relationship. This can be accomplished with arch bars (◘ Fig. 5.5a) and Risdon wires (◘ Fig. 5.5b). Patients are either wired together into maxillomandibular fixation or placed in elastics (heavy or guiding). Orthodontic brackets or intermaxillary fixation (IMF) screws (◘ Fig. 5.5c) can also be used in the appropriate clinical situations.

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Aug 25, 2019 | Posted by in General Dentistry | Comments Off on Trauma: Oral and Maxillofacial Surgical Issues
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